Form Department of the Treasury—Internal Revenue Service

1040A U.S. Individual Income Tax Return (99) 2016 IRS Use Only—Do not write or staple in this space.
Your first name and initial Last name OMB No. 1545-0074
Your social security number
LaQuana E Chappelle 072 72 7356
If a joint return, spouse’s first name and initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
c
329 bristol st E and on line 6c are correct.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign
brooklyn NY 11212 Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign country name Foreign province/state/county Foreign postal code a box below will not change your tax or
refund. You Spouse

Filing 1 Single 4 Head of household (with qualifying person). (See instructions.)

status 2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent,
Check only 3 Married filing separately. Enter spouse’s SSN above and enter this child’s name here. a
one box. full name here. a 5 Qualifying widow(er) with dependent child (see instructions)

}
Exemptions 6a Yourself. If someone can claim you as a dependent, do not check Boxes
checked on
box 6a. 6a and 6b 1
b Spouse No. of children
on 6c who:
c Dependents: (4)  if child under
(2) Dependent’s social (3) Dependent’s • lived with
age 17 qualifying for
If more than six security number relationship to you child tax credit (see
you 2
dependents, see (1) First name Last name instructions) • did not live
instructions. with you due to
Alexandria Chappelle 076-96-5664 Daughter divorce or
laquan e cameron 087-98-1840 Son separation (see
instructions)
Dependents
on 6c not
entered above

Add numbers
on lines
d Total number of exemptions claimed. above a 3
Income
7 Wages, salaries, tips, etc. Attach Form(s) W-2. 7 11,754.
Attach
Form(s) W-2 8a Taxable interest. Attach Schedule B if required. 8a
here. Also b Tax-exempt interest. Do not include on line 8a. 8b
attach
Form(s) 9a Ordinary dividends. Attach Schedule B if required. 9a
1099-R if tax b Qualified dividends (see instructions). 9b
was 10 Capital gain distributions (see instructions). 10
withheld. 11a IRA 11b Taxable amount
If you did not distributions. 11a (see instructions). 11b
get a W-2, see 12a Pensions and 12b Taxable amount
instructions.
annuities. 12a (see instructions). 12b

13 Unemployment compensation and Alaska Permanent Fund dividends. 13

14a Social security 14b Taxable amount
benefits. 14a (see instructions). 14b

15 Add lines 7 through 14b (far right column). This is your total income. a 15 11,754.
Adjusted
gross 16 Educator expenses (see instructions). 16
income 17 IRA deduction (see instructions). 17
18 Student loan interest deduction (see instructions). 18

19 Tuition and fees. Attach Form 8917. 19

20 Add lines 16 through 19. These are your total adjustments. 20

21 Subtract line 20 from line 15. This is your adjusted gross income. a 21 11,754.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040A (2016)
BAA REV 01/25/17 [Link]
Form 1040A (2016) Page 2
Tax, credits, 22 Enter the amount from line 21 (adjusted gross income). 22 11,754.
and
payments
23a Check
if: {
You were born before January 2, 1952,
Spouse was born before January 2, 1952,
Blind Total boxes
Blind checked a 23a }
b If you are married filing separately and your spouse itemizes
Standard deductions, check here a 23b
Deduction
for— 24 Enter your standard deduction. 24 9,300.
• People who 25 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-. 25 2,454.
check any
box on line 26 Exemptions. Multiply $4,050 by the number on line 6d. 26 12,150.
23a or 23b or
who can be 27 Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-.
claimed as a This is your taxable income. a 27 0.
dependent,
see 28 Tax, including any alternative minimum tax (see instructions). 28 0.
instructions.
29 Excess advance premium tax credit repayment. Attach
• All others:
Single or Form 8962. 29
Married filing 30 Add lines 28 and 29. 30 0.
separately,
$6,300 31 Credit for child and dependent care expenses. Attach
Married filing Form 2441. 31 0.
jointly or
Qualifying 32 Credit for the elderly or the disabled. Attach
widow(er),
$12,600 Schedule R. 32
Head of 33 Education credits from Form 8863, line 19. 33
household,
$9,300 34 Retirement savings contributions credit. Attach Form 8880. 34
35 Child tax credit. Attach Schedule 8812, if required. 35 0.
36 Add lines 31 through 35. These are your total credits. 36 0.
37 Subtract line 36 from line 30. If line 36 is more than line 30, enter -0-. 37 0.
38 Health care: individual responsibility (see instructions). Full-year coverage 38 0.
39 Add line 37 and line 38. This is your total tax. 39 0.
40 Federal income tax withheld from Forms W-2 and 1099. 40 1,148.
If you have
41 2016 estimated tax payments and amount applied
a qualifying from 2015 return. 41
child, attach 42a Earned income credit (EIC). 42a 4,710.
Schedule
EIC. b Nontaxable combat pay election. 42b
43 Additional child tax credit. Attach Schedule 8812. 43 1,313.
44 American opportunity credit from Form 8863, line 8. 44
45 Net premium tax credit. Attach Form 8962. 45
46 Add lines 40, 41, 42a, 43, 44, and 45. These are your total payments. a 46 7,171.
47 If line 46 is more than line 39, subtract line 39 from line 46.
Refund This is the amount you overpaid. 47 7,171.
Direct 48a Amount of line 47 you want refunded to you. If Form 8888 is attached, check here a 48a 7,171.
deposit?
See a b
Routing a c Type: Checking Savings
instructions number 0 2 6 0 0 8 8 1 1
and fill in
48b, 48c, a d
Account
and 48d or number 6 8 0 6 5 9 1 3 9 9
Form 8888. 49 Amount of line 47 you want applied to your
2017 estimated tax. 49
Amount 50 Amount you owe. Subtract line 46 from line 39. For details on how to pay,
you owe see instructions. a 50
51 Estimated tax penalty (see instructions). 51
Third party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete the following. No
Designee’s Phone Personal identification
designee name a no. a number (PIN) a

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
Sign and belief, they are true, correct, and accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other
than the taxpayer) is based on all information of which the preparer has any knowledge.
here Your signature Date Your occupation Daytime phone number
F

Joint return?
See instructions. social worker (347)693-7600
Keep a copy Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection
PIN, enter it
for your records.
here (see inst.)
Print/type preparer’s name Preparer’s signature Date PTIN
Paid Check a if
self-employed
preparer Firm's name a Firm's EIN a
Self-Prepared
use only Firm's address a Phone no.
REV 01/25/17 [Link] Form 1040A (2016)
SCHEDULE EIC Earned Income Credit OMB No. 1545-0074
(Form 1040A or 1040) 1040A `
a
Qualifying Child Information
Complete and attach to Form 1040A or 1040 only if you have a qualifying child.
..........

1040 2016
Department of the Treasury a
Information about Schedule EIC (Form 1040A or 1040) and its instructions is at [Link]/scheduleeic.
EIC Attachment
Internal Revenue Service (99) Sequence No. 43
Name(s) shown on return Your social security number
LaQuana E Chappelle 072-72-7356
• See the instructions for Form 1040A, lines 42a and 42b, or Form 1040, lines 66a and 66b, to make
Before you begin: sure that (a) you can take the EIC, and (b) you have a qualifying child.
• Be sure the child’s name on line 1 and social security number (SSN) on line 2 agree with the child’s social security card.
Otherwise, at the time we process your return, we may reduce or disallow your EIC. If the name or SSN on the child’s
social security card is not correct, call the Social Security Administration at 1-800-772-1213.

F
!
CAUTION
• You can't claim the EIC for a child who didn't live with you for more than half of the year.
• If you take the EIC even though you are not eligible, you may not be allowed to take the credit for up to 10 years. See the instructions for details.
• It will take us longer to process your return and issue your refund if you do not fill in all lines that apply for each qualifying child.

Qualifying Child Information Child 1 Child 2 Child 3

1 Child’s name First name Last name First name Last name First name Last name
If you have more than three qualifying
children, you have to list only three to get
the maximum credit. Alexandria Chappelle laquan E cameron
2 Child’s SSN
The child must have an SSN as defined in
the instructions for Form 1040A, lines 42a
and 42b, or Form 1040, lines 66a and 66b,
unless the child was born and died in
2016. If your child was born and died in
2016 and did not have an SSN, enter
“Died” on this line and attach a copy of
the child’s birth certificate, death
certificate, or hospital medical records.
076-96-5664 087-98-1840
3 Child’s year of birth
Year 2 0 0 6 Year 2 0 0 9 Year
If born after 1997 and the child is If born after 1997 and the child is If born after 1997 and the child is
younger than you (or your spouse, if younger than you (or your spouse, if younger than you (or your spouse, if
filing jointly), skip lines 4a and 4b; filing jointly), skip lines 4a and 4b; filing jointly), skip lines 4a and 4b;
go to line 5. go to line 5. go to line 5.

4 a Was the child under age 24 at the end of

2016, a student, and younger than you (or Yes. No. Yes. No. Yes. No.
your spouse, if filing jointly)?
Go to Go to line 4b. Go to Go to line 4b. Go to Go to line 4b.
line 5. line 5. line 5.

b Was the child permanently and totally

disabled during any part of 2016? Yes. No. Yes. No. Yes. No.
Go to The child is not a Go to The child is not a Go to The child is not a
line 5. qualifying child. line 5. qualifying child. line 5. qualifying child.

5 Child’s relationship to you

(for example, son, daughter, grandchild,
niece, nephew, foster child, etc.) Daughter Son
6 Number of months child lived
with you in the United States
during 2016

• If the child lived with you for more than

half of 2016 but less than 7 months,
enter “7.”
• If the child was born or died in 2016 and 12 months 12 months months
your home was the child’s home for more
than half the time he or she was alive Do not enter more than 12 Do not enter more than 12 Do not enter more than 12
during 2016, enter “12.” months. months. months.
For Paperwork Reduction Act Notice, see your tax BAA REV 01/25/17 [Link] Schedule EIC (Form 1040A or 1040) 2016
return instructions.
SCHEDULE 8812 1040 OMB No. 1545-0074
Child Tax Credit `
(Form 1040A or 1040)
a Attach to Form 1040, Form 1040A, or Form 1040NR.
1040A
1040NR 2016
Department of the Treasury
a Information about Schedule 8812 and its separate instructions is at 8812 Attachment
Internal Revenue Service (99) [Link]/schedule8812. Sequence No. 47
Name(s) shown on return Your social security number
LaQuana E Chappelle 072-72-7356
Part I Filers Who Have Certain Child Dependent(s) with an ITIN (Individual Taxpayer Identification Number)

F
!
CAUTION
Complete this part only for each dependent who has an ITIN and for whom you are claiming the child tax credit.
If your dependent is not a qualifying child for the credit, you cannot include that dependent in the calculation of this credit.

Answer the following questions for each dependent listed on Form 1040, line 6c; Form 1040A, line 6c; or Form 1040NR, line 7c, who has an ITIN
(Individual Taxpayer Identification Number) and that you indicated is a qualifying child for the child tax credit by checking column (4) for that
dependent.
A For the first dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

B For the second dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

C For the third dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

D For the fourth dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

Note: If you have more than four dependents identified with an ITIN and listed as a qualifying child for the child tax credit, see separate instructions
and check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a

Part II Additional Child Tax Credit Filers

}
1 If you file Form 2555 or 2555-EZ stop here; you cannot claim the additional child tax credit.

If you are required to use the worksheet in Pub. 972, enter the amount from line 8 of the Child Tax
Credit Worksheet in the publication. Otherwise:
1040 filers: Enter the amount from line 6 of your Child Tax Credit Worksheet (see the 1 2,000.
Instructions for Form 1040, line 52).
1040A filers: Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
Instructions for Form 1040A, line 35).
1040NR filers: Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
Instructions for Form 1040NR, line 49).
2 Enter the amount from Form 1040, line 52; Form 1040A, line 35; or Form 1040NR, line 49 . . . . . 2 0.
3 Subtract line 2 from line 1. If zero, stop here; you cannot claim this credit . . . . . . . . . . . 3 2,000.
4a Earned income (see separate instructions) . . . . . . . . . . . 4a 11,754.
b Nontaxable combat pay (see separate
instructions) . . . . . . . . . . . 4b
5 Is the amount on line 4a more than $3,000?
No. Leave line 5 blank and enter -0- on line 6.
Yes. Subtract $3,000 from the amount on line 4a. Enter the result . . . 5 8,754.
6 Multiply the amount on line 5 by 15% (0.15) and enter the result . . . . . . . . . . . . . . 6 1,313.
Next. Do you have three or more qualifying children?
No. If line 6 is zero, stop here; you cannot claim this credit. Otherwise, skip Part III and enter the
smaller of line 3 or line 6 on line 13.
Yes. If line 6 is equal to or more than line 3, skip Part III and enter the amount from line 3 on line 13.
Otherwise, go to line 7.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 01/25/17 [Link] Schedule 8812 (Form 1040A or 1040) 2016
Schedule 8812 (Form 1040A or 1040) 2016 Page 2
Part III Certain Filers Who Have Three or More Qualifying Children
7 Withheld social security, Medicare, and Additional Medicare taxes from
Form(s) W-2, boxes 4 and 6. If married filing jointly, include your spouse’s
amounts with yours. If your employer withheld or you paid Additional
Medicare Tax or tier 1 RRTA taxes, see separate instructions . . . . . . 7

}
8 1040 filers: Enter the total of the amounts from Form 1040, lines
27 and 58, plus any taxes that you identified using code
“UT” and entered on line 62.
1040A filers: Enter -0-. 8
1040NR filers: Enter the total of the amounts from Form 1040NR,
lines 27 and 56, plus any taxes that you identified using
code “UT” and entered on line 60.
9 Add lines 7 and 8 . . . . . . . . . . . . . . . . . . . 9

}
10 1040 filers: Enter the total of the amounts from Form 1040, lines
66a and 71.
1040A filers: Enter the total of the amount from Form 1040A, line
42a, plus any excess social security and tier 1 RRTA 10
taxes withheld that you entered to the left of line 46
(see separate instructions).
1040NR filers: Enter the amount from Form 1040NR, line 67.
11 Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 11
12 Enter the larger of line 6 or line 11 . . . . . . . . . . . . . . . . . . . . . . 12
Next, enter the smaller of line 3 or line 12 on line 13.
Part IV Additional Child Tax Credit
13 This is your additional child tax credit . . . . . . . . . . . . . . . . . . . . . 13 1,313.
Enter this amount on
1040 Form 1040, line 67,
Form 1040A, line 43, or
1040A Form 1040NR, line 64.
1040NR `

REV 01/25/17 [Link] Schedule 8812 (Form 1040A or 1040) 2016

 Tax History Report 2016
G Keep for your records

Name(s) Shown on Return

LaQuana E Chappelle

Five Year Tax History:

2012 2013 2014 2015 2016

Filing status HH

Total income 11,754.

Adjustments to income

Adjusted gross income 11,754.

Tax expense 724.

Interest expense

Contributions

Miscellaneous
deductions

Other Itemized
Deductions

Total itemized/
standard deduction 9,300.

Exemption amount 12,150.

Taxable income 0.

Tax

Alternative min tax

Total credits 0.

Other taxes 0.

Payments 7,171.

Form 2210 penalty

Amount owed

Applied to next
year’s estimated tax

Refund 7,171.

Effective tax rate % -51.24

**Tax bracket % 10.0

**Tax bracket % is based on Taxable income.

IMPORTANT DISCLOSURES

If you are owed a federal tax refund, you have a right to choose how you will receive the
refund. There are several options available to you. Some options cost money and some
options are free. Please read about these options below.

You can file your tax return electronically or by paper and obtain your refund directly from
Internal Revenue Service ("IRS") for free. If you file your tax return electronically, you can
receive a refund check directly from the IRS through the U.S. Postal Service in 21 to 28 days
from the time you file your tax return or the IRS can deposit your refund directly into your
bank account in less than 21 days from the time you file your tax return unless there are
delays by the IRS. If you file a paper return through the U.S. Postal Service, you can receive
a refund check directly from the IRS through the U.S. Postal Service in 6 to 8 weeks from the
time the IRS receives your return or the IRS can deposit your refund directly into your bank
account in 6 to 8 weeks from the time the IRS receives your return. However, if your return
contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your
refund no earlier than February 15, 2017.

You can file your tax return electronically, select the Refund Processing Service ("RPS")
for an additional fee of $34.99 (the "RPSfee"), and have your federal income tax refund processed
through a processor using bank services of a financial institution. The RPS allows your refund to
be deposited into a bank account intended for one-time use at Civista Bank ("Bank") and deducts
your TurboTax fees and other fees you authorize from your refund. The balanceis delivered to you
via the disbursement method you select. If you file your tax return electronically and select the
RPS, the IRS will deposit your refund with Bank. Upon receipt of your refund, Santa Barbara Tax
Products Group, LLC, a processor, will deduct and pay from your refund the RPS fee, any fees
charged by TurboTax for the preparation and filing of your tax return and any other amounts
authorized by you and disburse the balance of your refund proceeds to you. Unless there are delays
by the IRS, refunds are received in less than 21 days from the time you file your tax return
electronically. However, if your return contains Earned Income Credit Tax Additional Child Tax
Credit, the IRS will issue your refund no earlier than February 15, 2017.

The RPS is not necessary to obtain your refund. If you have an existing bank account,
you do not need to use the RPS, which requires the payment of a fee, in order to receive a
direct deposit from the IRS. You may consult the IRS website ([Link]) for information
about tax refund processing.

If you select the RPS, no prior debt you may owe to Bank will be deducted from your
refund.

You can change your income tax withholdings which might result in you receiving additional
funds throughout the year rather than waiting to receive these funds potentially in an
income tax refund next year. Please consult your employer or tax advisor for additional
details.

Information regarding low-cost deposit accounts may be available at [Link] .

The chart below shows the options for filing your tax return (e-file or paper return), the RPS
product, refund disbursement options, estimated timing for obtaining your tax refund
proceeds, and costs associated with the various options.
 WHAT TYPE WHAT ARE YOUR WHAT IS THE WHAT COSTS DO YOU
OF FILING DISBURSEMENT ESTIMATED TIME TO INCUR IN ADDITION
METHOD? OPTIONS? RECEIVE REFUND? TO TAX PREPARATION
FEES?

PAPER RETURN IRS direct deposit to Approximately No additional cost.

your personal bank 6 to 8 weeks 2
No Refund Processing account.
Service
Check mailed by IRS Approximately
to address on tax 6 to 8 weeks 2
return.

ELECTRONIC IRS direct deposit to Usually within 21 days2 No additional cost.

FILING your personal bank
(E-FILE) account.

No Refund Processing Check mailed by IRS Approximately

Service to address on tax 21 to 28 days 2
return.

ELECTRONIC (a) Direct deposit to Usually within $ 34.99

FILING your personal bank 21 days 2
(E-FILE) account, or

Refund Processing (b) Load to your

Service prepaid card 1.

1 You may incur additional charges from the issuer of the prepaid card if you select to have your tax
refund loaded on a prepaid debit card. Bank is not affiliated with the issuer of the prepaid card.
2 However, if your return contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will

issue your refund no earlier than February 15, 2017.

Questions? Call 1-877-908-7228

 Consent to Use of Tax Return Information

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your tax return information for purposes other than the preparation and filing of your tax return
without your consent.

You are not required to complete this form to engage our tax return preparation services.
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If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@[Link].

The following statements apply:

Sign this agreement by entering your name and the date below.

First Name Last Name

Date

[Link] 04/30/15
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This is an IRS requirement

The purpose of this agreement is to confirm that you are eligible for this payment option. By
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IRS regulations require the following statements:

"Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use
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your consent.

You are not required to complete this form to engage our tax return preparation services. If we obtain
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If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@[Link].

To agree, enter your name and date in the boxes below and select the "I Agree" button on the
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I authorize Intuit, the maker of TurboTax, to use the information provided in this 2016 return to
determine whether a portion of the refund can be used to pay for tax preparation.

Laquana Chappelle
First Name Last Name

Please type the date below:

02/06/2017
Date
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We transmit this information so that you may use this payment option. BANK and SBTPG will use
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IRS regulations require the following statements:

"Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
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If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@[Link].

To agree, enter your name and date in the boxes below and select the "I Agree" button on the
bottom of the page.

I authorize Intuit, the maker of TurboTax, to disclose to BANK and SBTPG that portion of my
2016 tax return information that is necessary to enable BANK and SBTPG to process
my refund.

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Date

[Link] 12/17/15
Read and accept this Disclosure Consent
This is an IRS requirement

In order to finalize your request for this payment option, we need to send the following information to
Civista Bank of Sandusky, OH (’BANK’) and to Santa Barbara Tax Products Group, LLC (’SBTPG’),
the administrator and servicer of this payment option: your identifying information, your deposit
information and your refund amount.

We transmit this information so that you may use this payment option. BANK and SBTPG will use
your information in accordance with their applicable refund processing service agreement and
privacy policy.

IRS regulations require the following statements:

"Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
disclose your tax return information to third parties for purposes other than the preparation and filing of
your tax return without your consent. If you consent to the disclosure of your tax return information,
Federal law may not protect your tax return information from further use or distribution.

You are not required to complete this form to engage our tax return preparation services. If we obtain
your signature on this form by conditioning our tax return preparation services on your consent, your
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valid for the amount of time that you specify. If you do not specify the duration of your consent, your
consent is valid for one year from the date of signature."

If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@[Link].

To agree, enter your name and date in the boxes below and select the "I Agree" button on the
bottom of the page.

I authorize Intuit, the maker of TurboTax, to disclose to BANK and SBTPG that portion of my
2016 tax return information that is necessary to enable BANK and SBTPG to process
my refund.

Sign this agreement by entering your name:

Laquana Chappelle

Please type the date below:

02/06/2017
Date

[Link] 12/17/15
 Form 8960 Form 8960 Worksheet 2016
Lines 4b, 5b, 7, 9, 10

Name(s) Shown on Return Your SSN

LaQuana E Chappelle 072-72-7356

Line 4b - Adjustment for trade or business income or loss

(a) Activity name (b) Gain or

loss

Enter additional adjustments not included above:

Adjustment for trade or business income not subject to net investment tax

Line 5b - Adjustment for gain or loss on dispositions

(a) Activity name (b) Gain or

loss

Capital loss carryover adjustment from 2015 for net investment tax purposes
Enter additional adjustments not included above and check the box if a capital gain or loss:

Net gain or loss from disposition of property not subject to net investment tax

Capital gain/loss not included in net investment income

(a) Activity name (b) Capital

Gain or Loss

Capital gain or loss from sale of property not subject to net investment income tax

Calculation of line 5b adjustment due to capital loss carryforward

1 Net capital loss not included in net investment income 1 0.

2 Capital loss carryover to next year 2
3 Lesser of line 1 or line 2 (Included as an adjustment on line 5b table above) 3 0.

Line 7 - Other modifications to investment income

1 Casualty and theft losses reported on Schedule A, line 20 1

2 Amounts reported on Form 8814, line 12 2
3 Adjustment for distributions from estates and trusts 3
4 Schedules C and F income/loss included in net investment income 4
5 Substitute interest and dividend payments 5
6 Recovery of a prior year deduction 6
7 7

8 Total other modifications to investment income 8

LaQuana E Chappelle 072-72-7356 Page 2

Line 9b - State income tax allocable to net investment income

1 State, local, and foreign income taxes 1

2 Investment income 2
3 Total adjusted gross income 3
4 Divide line 2 by line 3. Enter result as a decimal amount 4
5 State, local and foreign income taxes allocable to investment income 5

Line 10 - Tax preparations fees allocable to net investment income

1 Tax preparations fees 1

2 Investment income 2
3 Total adjusted gross income 3
4 Divide line 2 by line 3. Enter result as a decimal amount 4
5 Tax preparations fees allocable to investment income 5

Lines 9 and 10 - Application of Itemized Deduction Limitations Worksheet

Part I - Application of Section 67 to Deductions Properly Allocable to Investment Income

1 Enter the amount of Miscellaneous Itemized Deductions properly

allocable to investment income before any itemized deductions limitations:

2 Enter the total of all items listed on line 1 2

3 Enter the amount of all Miscellaneous Itemized Deductions after the application
of the section 67 limitation (Schedule A (Form 1040), line 27) 3
4 Enter the lesser of the total reported on line 2 or line 3 4

Part II - Application of Section 67 Limitation to Specific Deductions

(A) (B) (C)
Reenter the amounts and descriptions from Part I, line 1 Fraction Column A
(see Help) times B
x =
x =
x =
x =

Part III - Application of Section 68 to Deductions Properly Allocable to Investment Income

1 Enter the amount of Miscellaneous Itemized Deductions properly

allocable to investment income from Column(C) of Part II:

1
2 Enter the amount of state, local, and foreign income taxes that are properly
allocable to investment income 2
3 Enter the amount of other Itemized Deductions subject to the section 68
limitation and properly allocable to investment income before any itemized
deduction limitation:

3
4 Enter the total deductions properly allocable to investment income subject to
the section 68 limitation. Enter the sum of lines 1 through 3 4
5 Enter the amount of total itemized deductions allowed after the section 68
limitation. Form 1040, line 40 5
6 Enter all other itemized deductions allowed but not subject to the section 68
deduction limitation: 6
7 Subtract line 6 from line 5 7
8 Enter the lesser of line 7 or line 4 8
LaQuana E Chappelle 072-72-7356 Page 3

Part IV - Reconciliation of Schedule A Deductions to Form 8960 plus additional expenses, lines 9 and 10
(A) (B) (C)
Reenter the amounts and descriptions from Part III, lines 1-3 Fraction Column A
(see Help) times B
Miscellaneous Itemized Deductions properly allocable to Investment
Income reportable on Form 8960, line 9c:
1 x =
x =
x =
x =
Total miscellaneous investment expenses to Form 8960, line 9c

2 State, local, and foreign income taxes x =

Itemized Deductions Subject to Section 68 reportable on Form 8960, line 10:

3 x =
x =
x =
x =
Penalty on early withdrawal of savings
Other modifications:

Total additional modifications to Form 8960, line 10

Calculation of Former Passive Activity Suspended Losses Allowed as Deduction Against NII

1) Former Passive Activity Suspended Losses

(a) Activity name (b) Suspended (c) Suspended (d) Used against (e) Used against
12/31/2015 12/31/2016 activity other passive

2) Former Passive Activity Suspended Losses - Schedule D

(a) Activity name (b) Suspended (c) Suspended (d) Used against (e) Used against
12/31/2015 12/31/2016 activity other passive

3) Former Passive Activity Suspended Losses - Form 4797

(a) Activity name (b) Suspended (c) Suspended (d) Used against (e) Used against
12/31/2015 12/31/2016 activity other passive
 Federal Information Worksheet 2016
G Keep for your records
Part I ' Personal Information
Information in Part I is completely calculated from entries on Personal Information Worksheets.
Taxpayer: Spouse:
First name LaQuana First name
Middle initial E Suffix Middle initial Suffix
Last name Chappelle Last name
Social security no. 072-72-7356 Social security no.
Occupation social worker Occupation
Date of birth 04/14/1987 (mm/dd/yyyy) Date of birth (mm/dd/yyyy)
Age as of 1-1-2017 29 Age as of 1-1-2017
Daytime phone (347)693-7600 Ext Daytime phone Ext
Legally blind Legally blind
Date of death Date of death

Dependent of Someone Else: Dependent of Someone Else:

Can taxpayer be claimed as dependent of another Can spouse be claimed as dependent of another
person (such as parent)? Yes X No person (such as parent)? Yes No
If yes, was taxpayer claimed as dependent on that If yes, was spouse claimed as dependent on that
person’s return? Yes X No person’s return? Yes No

Credit for the Elderly or Disabled (Schedule R): Credit for the Elderly or Disabled (Schedule R):
Is the taxpayer retired on total Is the spouse retired on total
and permanent disability? Yes No and permanent disability? Yes No
Presidential Election Campaign Fund: Presidential Election Campaign Fund:
Does the taxpayer want $3 to go to the Presidential Does the spouse want $3 to go to the Presidential
Election Campaign Fund? Yes No Election Campaign Fund? Yes No

Part II ' Address and Federal Filing Status (enter information in this section)
Address 329 bristol st Apt no. E
City brooklyn State NY ZIP code 11212
Foreign code Foreign country
Foreign province/county Foreign postal code

APO/FPO/DPO address, check if appropriate APO FPO DPO

Home phone
Check to print phone number on Form 1040 Home X Taxpayer daytime Spouse daytime

Federal filing status:

1 Single
2 Married filing jointly
3 Married filing separately
Check this box if you did not live with your spouse at any time during the year
Check this box if you are eligible to claim your spouse’s exemption (see Help)
X 4 Head of household
If the ’qualifying person’ is your child but not your dependent:
Child’s First name MI Last Name Suff
Child’s social security number
5 Qualifying widow(er)
Check the appropriate box for the year your spouse died 2014
2015

Part III ' Dependent/Earned Income Credit/Child and Dependent Care Credit Information
Information in Part III is completely calculated from entries on Dependent/Nondependent Info Worksheets.
Date of birth Date of death
(mm/dd/yyyy) (mm/dd/yyyy)

Qualified
Not child/dep Lived
C qual care exps with Educ *
Social security o for incurred E taxpyr Tuitn D
First name MI number d child and paid I in and e
Last name Suff Relationship Age e tax cr 2016 C U.S. Fees p

Alexandria 076-96-5664 09/21/2006

Chappelle Daughter 10 L E 12 Yes
laquan E 087-98-1840 01/25/2009
cameron Son 7 L 541. E 12 Yes

* "Yes" - qualifies as dependent, "No" - does not qualify as dependent

LaQuana E Chappelle 072-72-7356 Page 2

Part IV ' Earned Income Credit Information (you must answer these questions to calculate EIC)
Is the taxpayer or spouse a qualifying child for EIC for another person? Yes X No
Was the taxpayer’s (and spouse’s if married filing jointly) home in the United States
for more than half of 2016? X Yes No
If the SSN of the taxpayer, or spouse if married filing jointly, was obtained to
get a federally funded benefit, such as Medicaid, and the Social Security card
contains the legend Not Valid for Employment, check this box (see Help)
Check if you are filing head of household and your spouse is a nonresident alien
and you lived with your spouse during the last six months of 2016
Was EIC disallowed or reduced in a previous year and are you required to file
Form 8862 this year? Yes X No
Check if you were notified by the IRS that EIC cannot be claimed in 2016 or
if you are ineligible to claim the EIC in 2015 for any other reason

Part V ' Direct Deposit or Direct Debit Information (not applicable for Form 9465)
Do you want to elect direct deposit of any federal tax refund? X Yes No

Do you want to elect direct debit of federal balance due (Electronic filing only)? Yes No

If you selected either of the options above, fill out the information below:
Name of Financial Institution (optional) Banco Popular
Check the appropriate box Checking X Savings
Routing number 026008811 Account number 6806591399

Enter the following information only if you are requesting direct debit of balance due:
Enter the payment date to withdraw from the account above
Balance-due amount from this return

Part VI ' Additional Information for Your Federal Return

Standard Deduction/Itemized Deductions:

Check this box if you are itemizing for state tax or other purposes even though your itemized
deductions are less than your standard deduction
Check this box if you are married filing separately and your spouse itemized deductions
Check this box to take the standard deduction even if less than itemized deductions

Main Form Selection:

Check this box to calculate Form 1040 even if you qualify to use Form 1040A or 1040EZ

Real Estate Professionals:

Do you or your spouse qualify for the special passive activity rules for
taxpayers in real property business? (see Help) Yes No

Credit for Qualified Retirement Savings Contributions (Form 8880):

Is the taxpayer a full-time student? Yes No
Is the spouse a full-time student? Yes No

Foreign Tax Credit (Form 1116):

Check this box to file Form 1116 even if you’re not required to file Form 1116
Resident country USA
Excludable Income from Am. Samoa, Guam, Commonwealth of the N. Mariana Islands, or Puerto Rico:
Excludable income of bona fide residents of American Samoa, Guam, or the
Commonwealth of the Northern Mariana Islands
Excludable income from Puerto Rico

Dual Status Alien Return:

Check this box if you are a dual-status alien

Third Party Designee:

Caution: Review transferred information for accuracy.
Do you want to allow another person to discuss this return with the IRS? Yes No
If Yes, complete the following:
Third party designee name
Third party designee phone number
Personal Identification number (enter any 5 numbers)
If you are entitled to a filing extension or other disaster relief provision as declared by the IRS,
enter the appropriate information (see Help)
LaQuana E Chappelle 072-72-7356 Page 3

Part VI ' Additional Information for Your Federal Return - Continued

Personal Representative for deceased taxpayers:

Name of personal representative required for E-filed
returns when Form 1310 is not filed or it is not the
surviving spouse

Part VII ' State Filing Information

Identity Protection PIN:

If the IRS sent the taxpayer an Identity Protection PIN, enter it here
If the IRS sent the spouse an Identity Protection PIN, enter it here

Taxpayer:
Enter the taxpayer’s state of residence as of December 31, 2016 NY
Check the appropriate box:
Taxpayer is a resident of the state above for the entire year X
Taxpayer is a resident of the state above for only part of year
Date the taxpayer established residence in state above
In which state (or foreign country) did the taxpayer reside before this change?
Spouse:
Enter the spouse’s state of residence as of December 31, 2016
Check the appropriate box:
Spouse is a resident of the state above for the entire year
Spouse is a resident of the state above for only part of year
Date the spouse established residence in state above
In which state (or foreign country) did the spouse reside before this change?

Nonresident states:

Nonresident State(s) Taxpayer/Spouse/Joint

Check this box if you are in a Registered Domestic Partnership or a civil union
If you checked the box on the line above, also check the appropriate box below:
Check if this is your individual federal return you are filing with the IRS
Check if this is the joint return created to file joint state tax return (see Help)
LaQuana E Chappelle 072-72-7356 Page 4

Use the PIN that you signed last year’s tax return with.
Taxpayer’s Prior year PIN
Spouse’s Prior year PIN

These signature PINs are chosen by the taxpayer and spouse and used for e-filing your tax return
Taxpayer’s PIN used to sign the return 27356
Spouse’s PIN used to sign the return

Taxpayer:
Drivers license or state ID number 551845768
Issued by what state NY
Expiration Date 04/14/2018
Issued Date 07/07/2016
License or ID license X ID neither
New York Document Number 0060508652
Spouse
Drivers license or state ID number
Issued by what state
Expiration Date
Issued Date
License or ID license ID neither
 Personal Information Worksheet 2016
For the Taxpayer
G Keep for your records
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Part I ' Taxpayer's Personal Information

First name LaQuana Middle initial Last name
E Chappelle
Suffix
Social security no. 072-72-7356 Member of U.S. Armed Forces in 2016? Yes No

Date of birth 04/14/1987 (mm/dd/yyyy) age as of 1-1-2017 29

Occupation social worker Daytime phone (347)693-7600 Ext

Marital status Single

If widowed, check the appropriate box for the year your spouse died:
After 2016 2016 2015 2014 Before 2014

Are you retired on total and permanent disability? (for Schedule R, see Help). Yes No
Check if this person is legally blind Yes X No
If deceased, enter the date of death (mm/dd/yyyy)

Were you under the age of 16 as of 1-1-2017 and this is the first year you
are filing a tax return? Yes No

Do you want $3 to go to Presidential Election Campaign Fund? Yes No

Part II ' Questions for Individuals Who Could Be Or Are Dependents of Another Taxpayer
1 Can someone (such as your parent) claim you as a dependent? Yes X No
2 If you answered ’Yes’ to question 1, are you actually claimed as a dependent
on that person’s tax return? Yes X No
Questions 3 through 5 are only required for individuals who claim the
American Opportunity Credit.
3 Were you a full-time student during any part of five months during 2016? Yes No
4 Did your earned income exceed one-half of your support? Yes No
5 Was at least one of your parents alive on December 31, 2016? Yes No

Part III ' Taxpayer's State Residency Information

Enter this person’s state of residence as of December 31, 2016 NY
Check the appropriate box:
This person is a resident of the state above for the entire year X
This person is a resident of the state above for only part of year
Date this person established residence in state above
In which state (or foreign country) did this person reside before this change?

Part IV ' Dependent Care Expenses

Qualified dependent care expenses incurred and paid for this person in 2016
Unreimbursed medical expenses paid for qualifying person in 2016
Employment taxes paid for dependent care providers in 2016
Full-time student for 5 calendar months during 2016? Yes No
Disabled person who was not physically or mentally capable of self-care? Yes No
This person is a qualifying person for the child and dependent care credit Yes X No

Part VI ' Healthcare Coverage

Does coverage in prior year qualify January and February for eligibility for
short gap exemption? See help for additional details. Yes X No

Prior year covered or exempt other than short gap exemption for November and
December, supports answer to January and February eligible for short gap exemption
above.
Check if covered or exempt (other than short gap) for prior year November
Check if covered or exempt (other than short gap) for prior year December

Check the appropriate box below to indicate the healthcare coverage for this person. Select 12 months
if they were covered all year, select the individual months if they were not covered all year and leave
blank if they did not have minimum essential during any month of the year.

12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
X X X X X X X X X X X X X
Enter any Marketplace-granted coverage exemption for this person below:
Exemption Certificate Number Exemption Start Month Exemption End Month

Enter any other insurance coverage exemption requested for this person below:
Exemption Type Check Full Year or Months Exempt for Each Type
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Full Year

Full Year

Full Year

Healthcare coverage information has been completed for this person.

 Personal Information Worksheet 2016
For the Spouse
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Part I ' Spouse's Personal Information

First name Middle initial Last name
Suffix
Social security no. Member of U.S. Armed Forces in 2016? Yes No

Date of birth (mm/dd/yyyy) age as of 1-1-2017

Occupation Daytime phone Ext

Marital status
If widowed, check the appropriate box for the year your spouse died:
After 2016 2016 2015 2014 Before 2014

Are you retired on total and permanent disability? (for Schedule R, see Help). Yes No
Check if this person is legally blind Yes No
If deceased, enter the date of death (mm/dd/yyyy)

Were you under the age of 16 as of 1-1-2017 and this is the first year you
are filing a tax return? Yes No

Do you want $3 to go to Presidential Election Campaign Fund? Yes No

Part II ' Questions for Individuals Who Could Be Or Are Dependents of Another Taxpayer
1 Can someone (such as your parent) claim you as a dependent? Yes No
2 If you answered ’Yes’ to question 1, are you actually claimed as a dependent
on that person’s tax return? Yes No
Questions 3 through 5 are only required for individuals who claim the
American Opportunity Credit.
3 Were you a full-time student during any part of five months during 2016? Yes No
4 Did your earned income exceed one-half of your support? Yes No
5 Was at least one of your parents alive on December 31, 2016? Yes No

Part III ' Spouse's State Residency Information

Enter this person’s state of residence as of December 31, 2016
Check the appropriate box:
This person is a resident of the state above for the entire year
This person is a resident of the state above for only part of year
Date this person established residence in state above
In which state (or foreign country) did this person reside before this change?

Part IV ' Dependent Care Expenses

Qualified dependent care expenses incurred and paid for this person in 2016
Unreimbursed medical expenses paid for qualifying person in 2016
Employment taxes paid for dependent care providers in 2016
Full-time student for 5 calendar months during 2016? Yes No
Disabled person who was not physically or mentally capable of self-care? Yes No
This person is a qualifying person for the child and dependent care credit Yes X No

Part VI ' Healthcare Coverage

Does coverage in prior year qualify January and February for eligibility for
short gap exemption? See help for additional details. Yes X No

Prior year covered or exempt other than short gap exemption for November and
December, supports answer to January and February eligible for short gap exemption
above.
Check if covered or exempt (other than short gap) for prior year November
Check if covered or exempt (other than short gap) for prior year December

Check the appropriate box below to indicate the healthcare coverage for this person. Select 12 months
if they were covered all year, select the individual months if they were not covered all year and leave
blank if they did not have minimum essential during any month of the year.

12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Enter any Marketplace-granted coverage exemption for this person below:
Exemption Certificate Number Exemption Start Month Exemption End Month

Enter any other insurance coverage exemption requested for this person below:
Exemption Type Check Full Year or Months Exempt for Each Type
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Full Year

Full Year

Full Year

Healthcare coverage information has been completed for this person.

 Dependent and Nondependent Information Worksheet 2016
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Part I ' Personal Information

First name Alexandria Middle initial Last name Chappelle

Suffix
Social security no. 076-96-5664

Date of birth 09/21/2006 (mm/dd/yyyy) age as of 12-31-2016 10

Did this person pass away in 2016 (deceased)? Yes No Date of death

Relationship to taxpayer or spouse Daughter

CAUTION: If claiming a child other than your own, see Relationship in the Tax Help.

NOTE: The ability to set your answers to being the same as last year for the dependent is only
available in Step-by-Step mode and not in Forms mode.
Are the answers to the questions below for this person, to determine
whether they are your dependent, the same as they were last year? Yes No

Dependency code * L Your dependent child who lived with you

*Dependency code is set based on your selections in the Dependency Exemption/EIC Smart Worksheet

Dependent is disabled X

Part II ' Earned Income Credit and Child Tax Credit

Is this person a U.S. citizen, U.S. national, or a U.S. resident? X Yes No

Is this person a resident of Canada or Mexico? Yes X No

This person is adopted and you are a U.S. citizen or U.S. national
The adopted child lived with you all year
*If the child is adopted, you are a U.S. citizen or U.S. national and they lived with you
all year, they are considered to meet the citizen test and the U.S. citizen box will
automatically be checked yes.

Child is a potentially qualifying child for earned income credit X Yes No

Child is a nondependent, but may qualify for earned income credit Yes No
You, and no one else, is claiming this nondependent for the earned income credit Yes No

Months lived with taxpayer in the United States 12

Qualifying for the earned income credit * E Qualifying child

*EIC code is set based on your selections in the Dependency Exemption/EIC Smart Worksheet

Check if this person is not a qualifying child for the child tax credit

If this dependent has an ITIN issued by the IRS instead of a Dependent has ITIN
social security number issued by the social security administration,
did they meet the substantial presence test? (see Schedule 8812 Instructions) Yes No
Dependent name Alexandria Chappelle Page 2

Part III ' Dependent Care Expenses

Qualified child or dependent care expenses incurred and paid in 2016

Unreimbursed medical expenses paid for qualifying person in 2016
Employment taxes paid for dependent care providers in 2016
Child or dependent is a qualifying person for the child and dependent care credit X Yes No
Child is a nondependent, but may qualify for the child and dependent care credit Yes No

Part V ' Dependent’s State Residency Information

Enter this person’s state of residence as of December 31, 2016

Check the appropriate box:
This person is a resident of the state above for the entire year
This person is a resident of the state above for only part of year
Date this person established residence in state above
In which state (or foreign country) did this person reside before this change?

Part VI ' Healthcare Coverage

Does coverage in prior year qualify January and February for eligibility for
short gap exemption? See help for additional details. Yes X No

Prior year covered or exempt other than short gap exemption for November and
December, supports answer to January and February eligible for short gap exemption
above.
Check if covered or exempt (other than short gap) for prior year November
Check if covered or exempt (other than short gap) for prior year December

Check the appropriate box below to indicate the healthcare coverage for this person. Select 12 months
if they were covered all year, select the individual months if they were not covered all year and leave
blank if they did not have minimum essential during any month of the year.

12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
X X X X X X X X X X X X X

Enter any Marketplace-granted coverage exemption for this person below:

Exemption Certificate Number Exemption Start Month Exemption End Month

Enter any other insurance coverage exemption requested for this person below:
Exemption Type Check Full Year or Months Exempt for Each Type
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Full Year

Full Year

Full Year

Healthcare coverage information has been completed for this person.

Part VI ' Identity Protection Pin

If the IRS sent an Identity Protection PIN for this dependent, enter it here
 Dependent and Nondependent Information Worksheet 2016
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Part I ' Personal Information

First name laquan Middle initial E Last name cameron

Suffix
Social security no. 087-98-1840

Date of birth 01/25/2009 (mm/dd/yyyy) age as of 12-31-2016 7

Did this person pass away in 2016 (deceased)? Yes X No Date of death

Relationship to taxpayer or spouse Son

CAUTION: If claiming a child other than your own, see Relationship in the Tax Help.

NOTE: The ability to set your answers to being the same as last year for the dependent is only
available in Step-by-Step mode and not in Forms mode.
Are the answers to the questions below for this person, to determine
whether they are your dependent, the same as they were last year? Yes No

Dependency code * L Your dependent child who lived with you

*Dependency code is set based on your selections in the Dependency Exemption/EIC Smart Worksheet

Dependent is disabled

Part II ' Earned Income Credit and Child Tax Credit

Is this person a U.S. citizen, U.S. national, or a U.S. resident? X Yes No

Is this person a resident of Canada or Mexico? Yes X No

This person is adopted and you are a U.S. citizen or U.S. national
The adopted child lived with you all year
*If the child is adopted, you are a U.S. citizen or U.S. national and they lived with you
all year, they are considered to meet the citizen test and the U.S. citizen box will
automatically be checked yes.

Child is a potentially qualifying child for earned income credit X Yes No

Child is a nondependent, but may qualify for earned income credit Yes No
You, and no one else, is claiming this nondependent for the earned income credit Yes No

Months lived with taxpayer in the United States 12

Qualifying for the earned income credit * E Qualifying child

*EIC code is set based on your selections in the Dependency Exemption/EIC Smart Worksheet

Check if this person is not a qualifying child for the child tax credit

If this dependent has an ITIN issued by the IRS instead of a Dependent has ITIN
social security number issued by the social security administration,
did they meet the substantial presence test? (see Schedule 8812 Instructions) Yes No
Dependent name laquan e cameron Page 2

Part III ' Dependent Care Expenses

Qualified child or dependent care expenses incurred and paid in 2016 541.
Unreimbursed medical expenses paid for qualifying person in 2016
Employment taxes paid for dependent care providers in 2016
Child or dependent is a qualifying person for the child and dependent care credit X Yes No
Child is a nondependent, but may qualify for the child and dependent care credit Yes No

Part V ' Dependent’s State Residency Information

Enter this person’s state of residence as of December 31, 2016

Check the appropriate box:
This person is a resident of the state above for the entire year
This person is a resident of the state above for only part of year
Date this person established residence in state above
In which state (or foreign country) did this person reside before this change?

Part VI ' Healthcare Coverage

Does coverage in prior year qualify January and February for eligibility for
short gap exemption? See help for additional details. Yes X No

Prior year covered or exempt other than short gap exemption for November and
December, supports answer to January and February eligible for short gap exemption
above.
Check if covered or exempt (other than short gap) for prior year November
Check if covered or exempt (other than short gap) for prior year December

Check the appropriate box below to indicate the healthcare coverage for this person. Select 12 months
if they were covered all year, select the individual months if they were not covered all year and leave
blank if they did not have minimum essential during any month of the year.

12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
X X X X X X X X X X X X X

Enter any Marketplace-granted coverage exemption for this person below:

Exemption Certificate Number Exemption Start Month Exemption End Month

Enter any other insurance coverage exemption requested for this person below:
Exemption Type Check Full Year or Months Exempt for Each Type
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Full Year

Full Year

Full Year

Healthcare coverage information has been completed for this person.

Part VI ' Identity Protection Pin

If the IRS sent an Identity Protection PIN for this dependent, enter it here
 Form 1040 Forms W-2 & W-2G Summary 2016
G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

Form W-2 Summary

Box No. Description Taxpayer Spouse Total

1 Total wages, tips and compensation:

Non-statutory & statutory wages not on Sch C 11,754. 11,754.
Statutory wages reported on Schedule C
Foreign wages included in total wages
Unreported tips
2 Total federal tax withheld 1,148. 1,148.
3 & 7 Total social security wages/tips 11,754. 11,754.
4 Total social security tax withheld 729. 729.
5 Total Medicare wages and tips 11,754. 11,754.
6 Total Medicare tax withheld 171. 171.
8 Total allocated tips
9 Not used
10 a Total dependent care benefits
b Offsite dependent care benefits
c Onsite dependent care benefits
11 Total distributions from nonqualified plans
12 a Total from Box 12
b Elective deferrals to qualified plans
c Roth contrib. to 401(k), 403(b), 457(b) plans
d Deferrals to government 457 plans
e Deferrals to non-government 457 plans
f Deferrals 409A nonqual deferred comp plan
g Income 409A nonqual deferred comp plan
h Uncollected Medicare tax
i Uncollected social security and RRTA tier 1
j Uncollected RRTA tier 2
k Income from nonstatutory stock options
l Non-taxable combat pay
m Total other items from box 12
14 a Total deductible mandatory state tax 8. 8.
b Total deductible charitable contributions
c This line does not apply to TurboTax
d Total RR Compensation
e Total RR Tier 1 tax
f Total RR Tier 2 tax
g Total RR Medicare tax
h Total RR Additional Medicare tax
i Total RRTA tips
j Total other items from box 14
16 Total state wages and tips 11,754. 11,754.
17 Total state tax withheld 416. 416.
19 Total local tax withheld 300. 300.
Form W-2 Wage and Tax Statement 2016
G Keep for your records

Name Social Security Number

LaQuana E Chappelle 072-72-7356

Spouse’s W-2 Military: Complete Part VI on Page 2 below

Do not transfer this W-2 to next year

a Employee’s social security No 072-72-7356 1 Wages, tips, other 2 Federal income

b Employer’s ID number 11-2777066 compensation tax withheld
c Employer’s name, address, and ZIP code 8,525.78 315.00
SCO FAMILY OF SERVICES 3 Social security wages 4 Social security tax withheld
8,525.73 528.61
Street ONE ALEXANDER PLACE 5 Medicare wages and tips 6 Medicare tax withheld
City GLEN COVE 8,525.73 123.63
State NY ZIP Code 11542 7 Social security tips 8 Allocated tips
Foreign Country
Verification Code 10 Dependent care benefits
d Control number
11 Nonqualified plans Distributions from sect. 457
X Transfer employee information from and nonqualified plans
the Federal Information Worksheet (Important, see Help)
e Employee’s name 12 Enter box 12 below
First LaQuana M.I. E
Last Chappelle Suff. 13 Statutory employee
f Employee’s address and ZIP code Retirement plan
Street 329 bristol st, Apt. E Third-party sick pay
City brooklyn
State NY ZIP Code 11212 14 Enter box 14 below after entering boxes 18, 19, and 20.
Foreign Country NOTE: Enter box 15 before entering box 14.

Box 12 Box 12 If Box 12 code is:

Code Amount A: Enter amount attributable to RRTA Tier 2 tax
M: Enter amount attributable to RRTA Tier 2 tax
P: Double click to link to Form 3903, line 4
R: Enter MSA contribution for Taxpayer
Spouse
W: Enter HSA contribution for Taxpayer
Spouse
G: Employer is not a state or local government

Box 15 Box 16 Box 17

State Employer’s state I.D. no. State wages, tips, etc. State income tax
NY 112777066 8,525.73 333.38

Box 20 Box 18 Box 19 Associated

Locality name Local wages, tips, etc. Local income tax State
NYC 8,525.73 216.82 NY

Box 14 TurboTax Identification of Description or Code

Description or Code (Identify this item by selecting the identification from
on Actual Form W-2 Amount the drop down list. If not on the list, select Other).
NYSDI 8.40 NY Nonoccupational Disability Fund tax
Form W-2 Wage and Tax Statement 2016
G Keep for your records

Name Social Security Number

LaQuana E Chappelle 072-72-7356

Spouse’s W-2 Military: Complete Part VI on Page 2 below

Do not transfer this W-2 to next year

a Employee’s social security No 072-72-7356 1 Wages, tips, other 2 Federal income

b Employer’s ID number 41-0760000 compensation tax withheld
c Employer’s name, address, and ZIP code 3,227.58 832.93
UNITED STATES POSTAL SERVICE EAG 3 Social security wages 4 Social security tax withheld
AN ACCOUNTING SERVICE CENTER 3,227.58 200.11
Street 2825 LONE OAK PARKWAY 5 Medicare wages and tips 6 Medicare tax withheld
City EAGAN 3,227.58 46.80
State MN ZIP Code 55121-9617 7 Social security tips 8 Allocated tips
Foreign Country
Verification Code 10 Dependent care benefits
d Control number
11 Nonqualified plans Distributions from sect. 457
X Transfer employee information from and nonqualified plans
the Federal Information Worksheet (Important, see Help)
e Employee’s name 12 Enter box 12 below
First LaQuana M.I. E
Last Chappelle Suff. 13 Statutory employee
f Employee’s address and ZIP code Retirement plan
Street 329 bristol st, Apt. E Third-party sick pay
City brooklyn
State NY ZIP Code 11212 14 Enter box 14 below after entering boxes 18, 19, and 20.
Foreign Country NOTE: Enter box 15 before entering box 14.

Box 12 Box 12 If Box 12 code is:

Code Amount A: Enter amount attributable to RRTA Tier 2 tax
M: Enter amount attributable to RRTA Tier 2 tax
P: Double click to link to Form 3903, line 4
R: Enter MSA contribution for Taxpayer
Spouse
W: Enter HSA contribution for Taxpayer
Spouse
G: Employer is not a state or local government

Box 15 Box 16 Box 17

State Employer’s state I.D. no. State wages, tips, etc. State income tax
NY 410760000 3,227.58 82.69

Box 20 Box 18 Box 19 Associated

Locality name Local wages, tips, etc. Local income tax State
NYC 3,227.58 82.69 NY

Box 14 TurboTax Identification of Description or Code

Description or Code (Identify this item by selecting the identification from
on Actual Form W-2 Amount the drop down list. If not on the list, select Other).
 Healthcare Entry Sheet 2016
G Keep for your records

The forms associated with healthcare (8965, 8962, 1095-A, 1095-B, 1095-C, and this Healthcare Entry Sheet) all interact with
information from the information worksheet. Be sure to enter all personal information including dependents listed on the return
before using this sheet to track health insurance coverage.

Yes No/Partial
Everyone on the tax return was covered by health insurance all year.

If everyone on the return was covered and there was no Market Place coverage (Form 1095-A) then check the YES box
above - no other action is required. The 1095-B or 1095-C can be used to verify coverage but you do not need to enter
the information if everyone on the return was covered.

Health Insurance Coverage for Individuals: Use this form to report healthcare coverage for individuals for months:
? not reported on 1095-A, 1095-B or 1095-C
? not covered by employer
? months not covered by an exemption

Note: The 1095-A information must be entered on Form 1095-A in order to correctly calculate any Premium Tax Credit. The 1095-B
or the 1095-C months can be entered directly in the table below.

If applicable enter information on form 1095-A, Health Insurance Marketplace Statement

Note: The IRS is not requiring the 1095-B or 1095-C be filed with the returns. To track the months covered you can either enter
on the 1095-B and/or 1095-C or check the boxes below

If applicable enter information on form 1095-B, Health Coverage

If applicable enter information on form 1095-C, Employer-Provided Health Insurance Offer and Coverage

If applicable enter Market Place exemptions (ECNs) or Request exemptions on form 8965

Note: Do not enter the name, SSN, or date of birth directly on the table below. Instead, enter the information at the bottom of the
Personal Information Worksheet or Dependent and Nondependent Information Worksheet.
Or if you check the box at the top "Yes" that "Everyone on the tax return was covered by health insurance all year." the covered
all 12 months box will be marked for all the individuals below regardless of what is entered on the Personal Information or
Dependent and Nondependent Information Worksheet.

Short Gap
Eligible*
Yes No
a. Name of covered individual(s) Covered all
b. SSN c. DOB 12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 LaQuana Chappelle Short gap: Yes X No
072-72-7356 04/14/87 X X X X X X X X X X X X X T
2 Alexandria Chappelle Short gap: Yes X No
076-96-5664 09/21/06 X X X X X X X X X X X X X 1
3 laquan cameron Short gap: Yes X No
087-98-1840 01/25/09 X X X X X X X X X X X X X 2
4 Short gap: Yes No

5 Short gap: Yes No

6 Short gap: Yes No

* See help for explanation of short gap Yes/No box function. It affects the calculation of short gap coverage for January and
February based on answer, which indicates whether coverage at end of prior year qualify months for short gap eligibility.

To review the detail of each person listed on the return (covered, not covered, exempt) and to see any penalty calculation go to the
Health Care Individual Responsibility Smart Worksheet on Form 8965
Completion checkbox:
X Check this box once you are finished with all the healthcare related entries.
 Wages, Salaries, & Tips Worksheet 2016
G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

The following amounts are included in the total entered on line 7 of Form 1040 (or Form 1040A), on line 1
of Form 1040EZ, on line 8 of Form 1040NR:

Taxpayer Spouse Total

1 Wages, from Form W-2 11,754. 11,754.

2 Miscellaneous income, from Form 8919
3 Items from Form 1099-R:
a Disability before minimum retirement age
b Return of contributions
4 Excess reimbursement, from Form 2106
5a Taxable tips, from Form 4137
b Noncash tips
6 Excess moving expense reimbursement,
from Form 3903
7 Wages earned as a household employee (if
less than $2,000 and without a Form W-2)
8 Items not on Form W-2 or Form 1099-R:
a Sick pay or disability payments
b Total foreign source income
c Check this box if the amount on line 8b is
eligible for the foreign exclusion/deduction
d Ordinary income from employer stock
transactions not reported on Form W-2
9 Other earned income

10 Subtotal.
Add lines 1 through 9 11,754. 11,754.
11 Taxable employer-provided dependent care
benefits, from Form 2441
12 Taxable employer-provided adoption benefits
less any excluded benefits from Form 8839
13 Scholarship/fellowship income not on
Form W-2
14 Other non-earned income

15 Total of lines 10 through 14 11,754. 11,754.

 Form 1040 Child Tax Credit Worksheet 2016
Line 52 G Keep for your records
Name as Shown on Return Social Security No.
LaQuana E Chappelle 072-72-7356
Note: ? To be a qualifying child for the child tax credit, the child must be under age 17 at the end of 2016
and meet the other requirements listed in the instructions for Form 1040 or 1040A.
? If applicable, first complete Form 2555, Foreign Earned Income and enter any exclusion of
income from U.S. Possessions on the Federal Information Worksheet.

Part 1
1 Number of qualifying children: 2 X $1,000. Enter the result 1 2,000.
2 Enter the amount from Form 1040, line 38, or
Form 1040A, line 22 2 11,754.
3 1040 filers: enter the total of any '
? Exclusion of income from Puerto Rico, and
? Amounts from Form 2555, lines 45 and 50;
Form 2555-EZ, line 18; and Form 4563, 3 0.
line 15.
1040A filers: Enter -0-.
4 Add lines 2 and 3. Enter the total 4 11,754.
5 Enter the amount shown below for your filing status.
? Married filing jointly ' $110,000
? Single, head of household, or
qualifying widow(er) ' $75,000 5 75,000.
? Married filing separately ' $55,000
6 Is the amount on line 4 more than the amount on
line 5?
X No. Leave line 6 blank. Enter -0- on line 7.
Yes. Subtract line 5 from line 4 6
If the result is not a multiple of $1,000,
increase it to the next multiple of $1,000.
For example, increase $425 to $1,000,
increase $1,025 to $2,000, etc.
7 Multiply the amount on line 6 by 5% (.05). Enter the result 7 0.
8 Is the amount on line 1 more than the amount on line 7?
No. Stop.
You cannot take the child tax credit on Form 1040, line 52, or
Form 1040A, line 35. You also cannot take the additional child tax
credit on Form 1040, line 67, or Form 1040A, line 43. Complete the
rest of your Form 1040 or 1040A.

X Yes. Subtract line 7 from line 1. Enter the result. Go to Part 2 8 2,000.
Part 2
9 Enter the amount from Form 1040, line 47, or Form 1040A, line 30 9 0.
10 Add the amounts from '
Form 1040, line 48
Form 1040, line 49, or Form 1040A, line 31 + 0.
Form 1040, line 50, or Form 1040A, line 33 +
Form 1040, line 51, or Form 1040A, line 34 +
Form 5695, line 30 +
Form 8910, line 15 +
Form 8936, line 23 +
Schedule R, line 22 +
Enter the total 10 0.
11 Are you claiming any of the following credits?
? Mortgage interest credit, Form 8396
? Adoption Credit, Form 8839
? Residential energy efficient property credit, Form 5695, Part I
? District of Columbia first-time homebuyer credit, Form 8859
X No. Enter the amount from line 10
Yes. If you are filing Form 2555, enter the amount from 11 0.
line 10. Otherwise, Complete the Line 11 Worksheet below to
figure the amount to enter here.
12 Subtract line 11 from line 9. Enter the result. 12 0.
13 Is the amount on line 8 of this worksheet more than the amount on line 12?
No. Enter the amount from line 8
X Yes. Enter the amount from line 12. This is your child
See the TIP below. tax credit 13 0.
Enter this amount on
Form 1040, line 52, or
Form 1040A, line 35.
TIP: You may be able to take the additional child tax credit on Form 1040, line 67, or Form 1040A,
line 43, only if you answered ’Yes’ on line 13.
? First, complete your Form 1040 through line 66a (also complete line 71), or Form 1040A through
line 42a.
? Then, use Parts II through IV of Schedule 8812 to figure any additional child tax credit.
 Schedule D Unrecaptured Section 1250 Gain Worksheet 2016
Line 19 G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

Regular Alternative
Tax Minimum Tax

If you are not reporting a gain on Form 4797, line 7, skip lines 1
through 9 and go to line 10.
1 If you have a section 1250 property in Part III of Form 4797 for
which you made an entry in Part I of Form 4797 (but not Form
6252), enter the smaller of line 22 or line 24 of Form 4797 for that
property. If you did not have any such property, go to line 4. 1
2 Enter the amount from Form 4797, line 26g, for the property for
which you made an entry on line 1 2
3 Subtract line 2 from line 1 3
4 Enter the total unrecaptured section 1250 gain included on lines
26 or 37 of Form(s) 6252 from installment sales of trade or
business property held more than one year 4
5 Enter the total of any amounts reported on a Schedule K-1 from a
partnership or an S corporation as "unrecaptured section 1250
gain". 5
6 Add lines 3 through 5 6
7 Enter the smaller of line 6 or the gain from Form
4797, line 7 7
8 Enter the amount, if any, from Form 4797, line 8 8
9 Subtract line 8 from line 7. If zero or less, enter -0- 9
10 Enter the amount of any gain from sale of an interest in a
partnership attributable to unrecaptured section 1250 gain 10
11 Enter the total of any amounts reported to you as "unrecaptured
section 1250 gain" from an estate, trust, real estate investment
trust or mutual fund
Regular AMT
a On Form 1099-DIV
b On Form 2439
c On Schedule(s) K-1
d On Form 1099-R
e From Form 8814
f Other
Total 11
12 Enter the total of any unrecaptured section 1250 gain from sales
(including installment sales) or other dispositions of section 1250
property held more than 1 year for which you did not make
an entry in Part I of Form 4797 for the year of sale 12
13 Add lines 9 through 12 13
14 If you had any section 1202 gain or collectibles gain or (loss),
enter the total of lines 1 thru 4 of the 28% Rate Gain Worksheet.
Otherwise, enter -0- 14 0. 0.
15 Enter the (loss), if any, from Schedule D, line 7. If Schedule D, line
7, is zero or a gain, enter -0- 15 0. 0.
16 Enter your long-term capital loss carryovers from Schedule D, line
14, and Schedule K-1 (Form 1041), line 11, code C 16
a Enter your capital gain excess, if you are filing Form 2555 a 0.
17 Combine lines 14 through 16a. If the result is a (loss), enter it as a
positive amount. If the result is zero or a gain, enter -0- 17 0. 0.
18 Unrecaptured section 1250 gain. Subtract line 17 from line 13. If
zero or less, enter -0-. If more than zero, enter the result here and
on Schedule D, line 19 18
 Schedule D 28% Rate Gain Worksheet 2016
Line 18 G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

Regular Alternative
Tax Minimum Tax

1 Enter the total of all collectibles gain or (loss) from items you
reported on Form 8949, Part II 1
2 Enter as a positive number the amount of any section 1202
exclusion you reported in column (g) of Form 8949, Part II, with
code "Q" in column (f), that is 50% of the gain, plus 2/3 of any
section 1202 exclusion you reported in column (g) of Form
8949, Part II, with code "Q" in column (f), that is 60% of the
gain, plus 1/3 of any section 1202 exclusion you reported in
column (g) of Form 8949, Part II, with code "Q" in column (f),
that is 75% of the gain.
50 % 60 % 75%
Exclusion Exclusion Exclusion
a Schedule D
b Form 8814
c Schedule B
d Form 6252
e Form 2439
f Other
Total 2
3 Enter the total of all collectibles gain or (loss) from:
Regular AMT
a Form 4684, line 4 (but only
if line 15 is more than zero)
b Form 6252
c Form 6781, Part II
d Form 8824
Total 3
4 Enter the total of any collectibles gain reported to you on:
Regular AMT
a Form 1099-DIV, box 2d
b Form 2439, box 1d
c Schedule K-1 from a
partnership, S corporation,
estate, or trust
d Disposition of interest in
partnership or S corporation
e Other
Total 4
5 Enter your long-term capital loss carryovers from Schedule D,
line 14, and Schedule K-1 (Form 1041), line 11, code C 5
6 If Schedule D, line 7, is a (loss), enter that (loss) here.
Otherwise, enter -0-. 6
7 Combine lines 1 through 6. If zero or less, enter -0-. If more
than zero, also enter this amount on Schedule D, line 18 7
8 Enter the amount of any capital gain excess 8 0.
9 Subtract line 8 from line 7. If zero or less, enter -0-.
Enter this amount on Schedule D Tax Worksheet, line 11a 9 0. 0.
 Form 1040 Schedule D Tax Worksheet 2016
Line 44 G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

1 a Enter your taxable income from Form 1040, line 43 1a 0.

b Enter the amount from your (and your spouse’s) Form 2555, line 45 b
c Add lines 1a and 1b 1c 0.
2 a Enter your qualified dividends
from Form 1040, line 9b 2a
b Enter any capital gain excess
attributable to qualified dividends b
c Subtract line 2b from line 2a 2c
3 Amount from Form 4952, line 4g 3
4 a Amount from Form 4952, line 4e 4 a
b Amount from the dotted line
next to Form 4952, line 4e b
c Line 4b, if applicable, 4a, if not c
5 Subtract line 4c from line 3. 5 0.
6 Subtract line 5 from line 2c. If zero or less, enter -0- 6 0.
7 a Enter line 15 of Schedule D 7a
b Enter line 16 of Schedule D b
c Enter the smaller of line 7a or line 7b 7c 0.
8 Enter the smaller of line 3 or line 4c 8
9 a Subtract line 8 from line 7. 9a 0.
b Enter any capital gain excess attributable to
capital gains b
c Subtract line 9b from line 9a 9c 0.
10 Add lines 6 and 9c 10 0.
11 a Enter the amount from Schedule D, line 18 11 a 0.
b Enter the amount from Schedule D, line 19 b
c Add lines 11a and 11b 11 c 0.
12 Enter the smaller of line 9c or line 11c 12 0.
13 Subtract line 12 from line 10 13 0.
14 Subtract line 13 from line 1c. If zero or less, enter -0- 14 0.
15 Enter:
? $37,650 if single or married filing separately;
? $75,300 if married filing jointly or qualifying widow(er); or 15 50,400.
? $50,400 if head of household.
16 Enter the smaller of line 1c or line 15 16 0.
17 Enter the smaller of line 14 or line 16 17 0.
18 Subtr ln 10 from ln 1c. If zero or less, enter -0- 18 0.
19 Enter the larger of line 17 or line 18 19 0.
20 Subtract line 17 from line 16. This amount is taxed at 0% 20 0.
If lines 1c and 16 are the same, skip lines 21 through 41
and go to line 42. Otherwise, go to line 21.
21 Enter the smaller of line 1c or line 13 21
22 Enter the amount from line 20 (if line 20 is blank, enter -0-) 22
23 Subtract line 22 from line 21. If zero or less, enter -0- 23
24 Enter:
? $415,050 if single,
? $233,475 if married filing separately, 24
? $466,950 if married filing jointly or qualifying widow(er),
? $441,000 if head of household.
25 Enter the smaller of line 1c or line 24 25
26 Add lines 19 and 20 26
27 Subtract line 26 from line 25. If zero or less, enter -0- 27
28 Enter the smaller of line 23 or line 27 28
29 Multiply line 28 by 15% (.15) 29
30 Add lines 22 and 28 30
31 Subtract line 30 from line 21 31
32 Multiply line 31 by 20% (.20) 32

If Schedule D, line 19, is zero or blank, skip lines 33 through 38

and go to line 39. Otherwise, go to line 33.
33 Enter the smaller of line 9c above or Schedule D, line 19 33
34 Add lines 10 and 19 34
35 Enter the amount from line 1c above 35
36 Subtract line 35 from line 34. If zero or less, enter -0- 36
37 Subtract line 36 from line 33. If zero or less, enter -0- 37
38 Multiply line 37 by 25% (.25) 38
 If Schedule D, line 18, is zero or blank, skip lines 39 through 41
and go to line 42. Otherwise, go to line 39.
39 Add lines 19, 20, 28, 31, and 37 39
40 Subtract line 39 from line 1c 40
41 Multiply line 40 by 28% (.28) 41

42 Figure the tax on the amount on line 19. If the amount on line 19 is less than $100,000,
use the Tax Table to figure this tax. If the amount on line 19 is $100,000 or more,
use the Tax Computation Worksheet 42
43 Add lines 29, 32, 38, 41, and 42 43 0.
44 Figure the tax on the amount on line 1c. If the amount on line 1c is less than $100,000,
use the Tax Table to figure this tax. If the amount on line 1c is $100,000 or more,
use the Tax Computation Worksheet 44
45 Tax on all taxable income (including capital gains and qualified dividends).
Enter the smaller of line 43 or line 44. Also include this amount on Form 1040, line 44 45
 Form 1040 Qualified Dividends and Capital Gain Tax Worksheet 2016
Line 44 G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

1 Enter the amount from Form 1040, line 43 1

2 Enter the amount from Form
1040, line 9b 2
3 Are you filing Schedule D?
Yes. Enter the smaller of line 15
or 16 of Schedule D. If
either line 15 or 16 is blank
or loss, enter -0- 3
No. Enter the amount from Form
1040, line 13.
4 Add lines 2 and 3 4
5 If filing Form 4952 (used to figure
investment interest expense
deduction), enter any amount from line
4g of that form. Otherwise, enter -0-. 5
6 Subtract line 5 from line 4. If zero or less, enter -0- 6
7 Subtract line 6 from line 1. If zero or less, enter -0- 7
8 Enter:
$37,650 if single or married filing separately,
$75,300 if married filing jointly or qualifying widow(er), 8
$50,400 if head of household.
9 Enter the smaller of line 1 or line 8 9
10 Enter the smaller of line 7 or line 9 10
11 Subtract line 10 from line 9 (this amount taxed at 0%) 11
12 Enter the smaller of line 1 or line 6 12
13 Enter the amount from line 11 13
14 Subtract line 13 from line 12. 14
15 Enter:
$415,050 if single,
$233,475 if married filing separately, 15
$466,950 if married filing jointly or qualifying widow(er),
$441,000 if head of household.
16 Enter the smaller of line 1 or line 15 16
17 Add lines 7 and 11 17
18 Subtract line 17 from line 16. If zero or less, enter -0- 18
19 Enter the smaller of line 14 or line 18 19
20 Multiply line 19 by 15% (.15) 20
21 Add lines 11 and 19 21
22 Subtract line 21 from line 12 22
23 Multiply line 22 by 20% (.20) 23
24 Figure the tax on the amount on line 7. If the amount on line 7 is less than
$100,000, use the Tax Table to figure the tax. If the amount on line 7 is
$100,000 or more, use the Tax Computation Worksheet 24
25 Add lines 20, 23, and 24 25
26 Figure the tax on the amount on line 1. If the amount on line 1 is less than
$100,000, use the Tax Table to figure this tax. If the amount on line 1 is
$100,000 or more, use the Tax Computation Worksheet 26
27 Tax on all taxable income. Enter the smaller of line 25 or line 26 here and on
Form 1040, line 44. 27
 Tax Payments Worksheet 2016
G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

Estimated Tax Payments for 2016 (If more than 4 payments for any state or locality, see Tax Help)

Federal State Local

Date Amount Date Amount ID Date Amount ID

1 04/18/16 04/18/16 04/18/16

2 06/15/16 06/15/16 06/15/16

3 09/15/16 09/15/16 09/15/16

4 01/17/17 01/17/17 01/17/17

Tot Estimated
Payments

Tax Payments Other Than Withholding Federal State ID Local ID

(If multiple states, see Tax Help)

6 Overpayments applied to 2016

7 Credited by estates and trusts
8 Totals Lines 1 through 7
9 2016 extensions

Taxes Withheld From: Federal State Local

10 Forms W-2 1,148. 416. 300.

11 Forms W-2G
12 Forms 1099-R
13 Forms 1099-MISC, 1099-K and 1099-G
14 Schedules K-1
15 Forms 1099-INT, DIV and OID
16 Social Security and Railroad Benefits
17 Form 1099-B St Loc
18 a Other withholding St Loc
b Other withholding St Loc
c Other withholding St Loc
d Positive Adjustment St Loc
e Negative Adjustment St Loc
f Additional Medicare Tax
19 Total Withholding Lines 10 through 18f
1,148. 416. 300.
20 Total Tax Payments for 2016 1,148. 416. 300.

Prior Year Taxes Paid In 2016 State ID Local ID

(If multiple states or localities, see Tax Help)

21 Tax paid with 2015 extensions

22 2015 estimated tax paid after 12/31/2015
23 Balance due paid with 2015 return
24 Other (amended returns, installment payments, etc)
 Schedule A Tax and Interest Deduction Worksheet 2016
Lines 5 - 12 G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

Tax Deductions

1 State and local taxes:

Optional Sales Tax Tables
a Available Income:
(1) Income from Form 1040, line 38 11,754.
(2) Nontaxable income entered elsewhere on return
(3) Available income: 2015 refundable credits in excess of tax 0.
(4) Enter any additional nontaxable income
(5) Total available income 11,754.
b Sales Tax Per State of Residence:
Enter state in column (1), then enter total (combined) state and local sales tax rate in column (4).
Arizona, Colorado, Illinois, Louisiana, Mississippi or New York only:
Double-click in column (4) to select your locality for each state entered.

(1) (2) (3) (4) (5) (6) (7) (8) (9)

S Date Date Enter State Local State Local Prorated
t Lived in Lived in Total Sales Sales Sales Sales or Total
a State State State & Tax Tax Tax Tax Amount
t From To Local Rate Rate (%) Table Amount
e Rate (%) (%) (4) - (5) Amount

c Total general sales tax using tables

d Sales Tax Paid on Specific Items (see help):

(1) (2) (3) (4) (5) (6) (7) (8)

ST Total Description Type Cost Rate if Actual Specific
State & Different Sales Tax Item
Local Amount Deduction
Rate Paid

e Total sales tax deduction on specific items

f Total general sales tax per tables plus sales tax on specific items
g Actual State and Local General Sales Tax:
Actual sales taxes (enter the total sales taxes paid during the year on all items)
h State and Local Income Taxes:
State and Local Income taxes 724.00
i State and Local Tax Deduction to Schedule A, line 5:
Greater of line 1f, line 1g, or line 1h (to Schedule A, line 5) 724.00
j Check a box to choose to use income taxes paid, sales taxes paid, or whichever
provides the greater deduction:
Income Taxes Sales Taxes Greater amount X

2 Real estate taxes:

a Real estate taxes paid on principal residence not entered on Form 1098
 b Real estate taxes paid on principal residence entered on Home Mortgage Int. Wks
c Real estate taxes paid on additional homes or land
Personal portion of real estate taxes from Schedule E Worksheet for:
d Principal residence
e Vacation home
f Less real estate taxes deducted on Form 8829
g Add lines 2a through 2f (to Schedule A, line 6)
3 Personal property taxes:
a Auto registration fees based on the value of the vehicle.
2015 Amount Enter 2016 description:

b Non-business portion of personal property taxes from Car & Truck Exp Wks
c Other personal property taxes
d Add lines 3a through 3c (to Schedule A, line 7)
4 Other taxes:
a Other taxes from Schedule(s) K-1
b Foreign taxes from interest and dividends
c Foreign taxes from Schedule(s) K-1
d Other foreign taxes (not used to claim a foreign tax credit)
e Other taxes.
2015 Amount Enter 2016 description:

f Add lines 4a through 4e (to Schedule A, line 8)

Interest Deductions

5 Home mortgage interest and points reported on Form 1098:

a Mortgage interest and points from the Home Mortgage Interest Worksheet
b Qualified mortgage interest from Schedule E Worksheet
c Less home mortgage interest/points deducted on Form 8829
d Less home mortgage interest from Form 8396, line 3
e Add lines 5a through 5d (to Sch A, line 10) or line A2 from above
6 Home mortgage interest not reported on Form 1098:
a Mortgage interest from the Home Mortgage Interest Worksheet
b Less home mortgage interest deducted on Form 8829
c Add lines 6a and 6b (to Sch A, line 11) or line B2 from above
7 Points not reported on Form 1098:
a Amortizable points from the Home Mortgage Interest Worksheet
b Other points not on Form 1098 from the Home Mortgage Interest Worksheet
c Less points deducted on Form 8829
d Add lines 7a through 7c (to Schedule A, line 12) or line C2 from above
 Schedule A State and Local Tax Deduction Worksheet 2016
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State and Local Income Taxes

State income taxes:

1 State income tax withheld 1 416.
2 2016 state estimated taxes paid in 2016 2
3 2015 state estimated taxes paid in 2016 3
4 Amount paid with 2015 state application for extension 4
5 Amount paid with 2015 state income tax return 5
6 Overpayment on 2015 state income tax return applied to 2016 tax 6
7 Other amounts paid in 2016 (amended returns, installment payments, etc.) 7
8 State estimated tax from Schedule(s) K-1 (Form 1041) 8
Local income taxes:
9 Local income tax withheld 9 300.
10 2016 local estimated taxes paid in 2016 10
11 2015 local estimated taxes paid in 2016 11
12 Amount paid with 2015 local application for extension 12
13 Amount paid with 2015 local income tax return 13
14 Overpayment on 2015 local income tax return applied to 2016 tax 14
15 Other amounts paid in 2016 (amended returns, installment payments, etc.) 15
16 Local estimated tax from Schedule(s) K-1 (Form 1041) 16
Other:
17 State mandatory taxes 17 8.
18 Total Add lines 1 through 17 18 724.
19 State and local refund allocated to 2016 19
20 Nondeductible state income tax from line 28 20
21 Total reductions Add lines 19 and 20. 21
22 Total state and local income tax deduction Line 18 less line 21 22 724.

Nondeductible State Income Tax (Hawaii Only)

23 Nontaxable federal employee cost of living allowance 23

24 Adjusted gross income 24
25 Add lines 23 and 24 25
26 Nondeductible percent. Line 23 divided by line 25 26 %
27 Hawaii state income tax included in line 18 27
28 Nondeductible Hawaii state income tax. Multiply line 26 by line 27. 28
 Charitable Deduction Limits Worksheet 2016
For Current Year Contributions
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Step 1. List your qualified charitable contributions made during the year.
1 RESERVED for future use
Step 2. List your other charitable contributions made during the year.
2 Enter your contributions to 50% limit organizations. Do not include contributions of capital
gain property deducted at fair market value. Do not include contributions entered on line 1.
3 Enter your contributions to 50% limit organizations of capital gain property deducted at fair
market value
4 Enter your contributions (other than of capital gain property) to organizations that are not
50% limit organizations
5 Enter your contributions "for the use" of any qualified organization
6 Add lines 4 and 5
7 Enter your contributions of capital gain property to or for the use of any qualified
organization. (But do not enter here any amount entered on line 1 or 2)
Step 3. Figure your deduction for the year and your carryover to the next year.
8 Enter your adjusted gross income 11,754.
9 Multiply line 8 by 0.5. This is your 50% limit. 5,877.

Limits Deduct Carryover

this year to next
Cash and Other Capital gain year

50% Other 50% Other

Org Org

Contributions to 50% limit

organizations
10 Enter the smaller of line 2 or line 9 0.
11 Subtract line 10 from line 2 0.
12 Subtract line 10 from line 9 5,877.

Contributions not to 50% limit

organizations
13 Add lines 2 and 3
14 Multiply line 8 by 0.3. This is your 30%
limit. 3,526. 3,526.
15 Subtract line 13 from line 9 5,877.
16 Enter the smallest of line 6, 14, or 15 0.
17 Subtract line 16 from line 6 0.
18 Subtract line 16 from line 14 3,526.

Capital gain property to 50% limit

organizations
19 Enter the smallest of line 3, 12, or 14 0.
20 Subtract line 19 from line 3 0.
21 Subtract line 16 from line 15 5,877.
22 Subtract line 19 from line 14 3,526.

Capital gain property not to 50% limit

organizations
23 Multiply line 8 by 0.2. This is your 20%
limit. 2,351.
24 Enter the smaller of line 7, 18, 21, 22,
or 23 0.
25 Subtract line 24 from line 7 0.

26 Add lines 10, 16, 19, and 24.

Amount for Schedule A, Line 19 0.
27 Reserved for future use
28 Reserved for future use
29 Reserved for future use
30 Add lines 11, 17, 20, and 25. Carry
to next year. 0.
 Charitable Deduction Limits Worksheet 2016
For Carryover Contributions
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Step 1. List your qualified charitable contributions made during the year.
1 RESERVED for future use
Step 2. List your other charitable contributions made during the year.
2 Enter your contributions to 50% limit organizations. Do not include contributions of capital
gain property deducted at fair market value. Do not include contributions entered on line 1.
3 Enter your contributions to 50% limit organizations of capital gain property deducted at fair
market value
4 Enter your contributions (other than of capital gain property) to organizations that are not
50% limit organizations
5 Enter your contributions "for the use" of any qualified organization
6 Add lines 4 and 5
7 Enter your contributions of capital gain property to or for the use of any qualified
organization. (But do not enter here any amount entered on line 1 or 2)
Step 3. Figure your deduction for the year and your carryover to the next year.
8 Enter your adjusted gross income 11,754.
9 Multiply line 8 by 0.5. This is your 50% limit. 5,877. less 0. 5,877.

Limits Deduct Carryover

this year to next
Cash and Other Capital gain year

50% Other 50% Other

Org Org

Contributions to 50% limit

organizations
10 Enter the smaller of line 2 or line 9 0.
11 Subtract line 10 from line 2 0.
12 Subtract line 10 from line 9 5,877.

Contributions not to 50% limit

organizations
13 Add lines 2 and 3 0.
14 Multiply line 8 by 0.3. This is your 30%
limit. 3,526. 3,526.
15 Subtract line 13 from line 9 5,877.
16 Enter the smallest of line 6, 14, or 15 0.
17 Subtract line 16 from line 6 0.
18 Subtract line 16 from line 14 3,526.

Capital gain property to 50% limit

organizations
19 Enter the smallest of line 3, 12, or 14 0.
20 Subtract line 19 from line 3 0.
21 Subtract line 16 from line 15 5,877.
22 Subtract line 19 from line 14 3,526.

Capital gain property not to 50% limit

organizations
23 Multiply line 8 by 0.2. This is your 20%
limit. 2,351.
24 Enter the smaller of line 7, 18, 21, 22,
or 23 0.
25 Subtract line 24 from line 7 0.

26 Add lines 10, 16, 19, and 24.

Amount for Schedule A, Line 19 0.
27 Reserved for future use
28 Reserved for future use
29 Reserved for future use
30 Add lines 11, 17, 20, and 25. Carry
to next year. 0.
 Charitable Contributions Summary 2016
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Part I Cash Contributions Summary
(a) (b) (c) (d)
Name of Charitable Organization Total 50% 30% RESERVED
Limit Limit for future
use

Totals:

Part II Non-Cash Contributions Summary

Total Other Property Capital Gain Property

(a) (b) (c) (d) (e)

Name of Charitable Organization Total 50% 30% 30% 20%
Limit Limit Limit Limit

Totals:
Part III Contribution Carryovers to 2017
Total Cash and Other Capital Gain
Non-Capital Gain Property Property
(a) (b) (c) (d) (e) (f)
Total RESERVED 50% 30% 30% 20%
Limit Limit Limit Limit
1 2016 contributions
2 2016 contributions
allowed 0. 0. 0. 0. 0.
3 Carryovers from:
a 2015 tax year
b 2014 tax year
c 2013 tax year
d 2012 tax year
e 2011 tax year
4 Carryovers
allowed in 2016 0. 0. 0. 0. 0.
5 Carryovers
disallowed in 2016 0. 0. 0. 0. 0.
6 Carryovers to 2017:
a From 2016 0. 0. 0. 0. 0.
b From 2015
c From 2014
d From 2013
e From 2012
f From 2011

Part IV Special Situations in Your Return for Current Year Donations

1 Was the entire interest given for all property donated to all charities? X Yes No
2 Were restrictions attached to any charities’s right
to use or dispose of any property donated to any charity? Yes X No
3 Did you give to anyone other than the charity the right to income from any
of the donated property or to possession of any of the donated property? Yes X No
4 Was any charity other than a 50% charity? Yes X No
 Schedule A Itemized Deductions Worksheet 2016
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1 Add the amounts on Schedule A, lines 4, 9, 15, 19, 20, 27 and 28 1 724.
2 Add the amounts on Schedule A, lines 4, 14 and 20, plus any gambling
and casualty or theft losses included on line 28 2
CAUTION: Be sure your total gambling and casualty or theft losses are clearly
identified on the Miscellaneous Itemized Deductions Statement.
3 Is the amount on line 2 less than the amount on line 1?
No. STOP. Your deduction is not limited. Enter the amount from
line 1 above on Schedule A, line 29.
X Yes. Subtract line 2 from line 1 3 724.
4 Multiply line 3 by 80% (.80) 4 579.
5 Enter the amount from Form 1040, line 38 5 11,754.
6 Enter $259,400 if single; $311,300 if married filing
jointly or qualifying widow(er); $285,350 if head of
household, $155,650 if married filing separately 6 285,350.
7 Is the amount on line 6 less than the amount on
line 5?
X No. STOP. Your deduction is not limited.
Enter the amount from line 1 above on
Schedule A, line 29.
Yes. Subtract line 6 from line 5 7
8 Multiply line 7 by 3% (.03) 8
9 Enter the smaller of line 4 or line 8 9
10 Total itemized deductions. Subtract line 9 from line 1.
(to Schedule A, line 29) 10
 Form 1040 Standard Deduction Worksheet for Dependents 2016
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Use this worksheet only if someone can claim you, or your spouse if filing jointly, as a dependent.
1 Is your earned income* more than $700?
Yes. Add $350 to your earned income. Enter the total 1
No. Enter $1,050
2 Enter the amount shown below for your filing status.
? Single or married filing separately ' $6,300
? Married filing jointly or Qualifying widow(er) ' $12,600 2 9,300.
? Head of household ' $9,300
3 Standard deduction.
3 a Enter the smaller of line 1 or line 2. If born after January 1, 1952, and not
blind, stop here and enter this amount on Form 1040, line 40. Otherwise go
to line 3b 3a
3 b If born before January 2, 1952, or blind, multiply the number on Form 1040,
line 39a, by $1,250 ($1,550 if single or head of household) 3b
3 c Add lines 3a and 3b. Enter the total here and on Form 1040, line 40 3c

*Earned income includes wages, salaries, tips, professional fees, and other compensation received for
personal services you performed. It also includes any amount received as a scholarship that you must
include in your income. Generally, your earned income is the total of the amount(s) you reported on Form
1040, lines 7, 12, and 18, minus the amount, if any, on line 27; or on Form 1040A, line 7.
 Form 1040 Deduction for Exemptions Worksheet 2016
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1 Multiply $4,050 by the total number of exemptions claimed on Form

1040, line 6d 1 12,150.
2 Enter the amount from Form 1040, line 38 2 11,754.
3 Enter the amount shown below for your filing status:
? Single, enter $259,400
? Married filing jointly or qualifying widow(er), enter $311,300
? Married filing separately, enter $155,650
? Head of household, enter $285,350 3 285,350.
4 Subtract line 3 from line 2. If zero or less, stop; enter the amount from
line 1 above on Form 1040, line 42 4 -273,596.
5 Is line 4 more than $122,500 ($61,250 if married filing separately)?
Yes. You cannot take a deduction for exemptions.
Enter zero here and on Form 1040, line 42.
Do not complete the rest of this worksheet.
No. Divide line 4 by $2,500 ($1,250 if married filing separately). If the
result is not a whole number, increase it to the next whole number
(for example, increase .0004 to 1) 5
6 Multiply line 5 by 2% (.02) and enter the result as a decimal 6
7 Multiply line 1 by line 6 7
8 Deduction for exemptions. Subtract line 7 from line 1. Enter the result here
and on Form 1040, line 42 8
 Earned Income Worksheet 2016
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Part I ' Earned Income Credit Wks Computation Taxpayer Spouse Total

1 If filing Schedule SE:

a
Net self-employment income
b
Optional Method and Church Employee income
c
Add lines 1a and 1b
d
One-half of self-employment tax
e
Subtract line 1d from line 1c
2 If not required to file Schedule SE:
a Net farm profit or (loss)
b Net nonfarm profit or (loss)
c Add lines 2a and 2b
3 If filing Schedule C or C-EZ as a statutory
employee, enter the amount from line 1
of that Schedule C or C-EZ
4 Add lines 1e, 2c and 3. To EIC Wks, line 5

Part II ' Form 2441 and Standard Deduction Worksheet Computations

5 Net self-employment earnings (line 4 above)

6 Wages, salaries, and tips less distributions
from nonqualified or section 457 plans, etc 11,754. 11,754.
7a Taxable employer-provided adoption benefits
b Foreign earned income exclusion
8 Add lines 5 through 7b. To Form 2441, lines 19
and 20 11,754. 11,754.
9a Taxable dependent care benefits
b Nontaxable combat pay
10 Add lines 8, 9a & 9b . To Form 2441, lines
4 and 5 11,754. 11,754.
11 Scholarship or fellowship income not on W-2
12 SE exempt earnings less nontaxable income
13 Distributions from nonqualified/Sec. 457 plans
14 Add lines 5, 6, 7a, 9a and 11 through 13.
To Standard Deduction Worksheet 11,754. 11,754.

Part III ' IRA Deduction Worksheet Computation

15 Net self-employment income or (loss)

16 Wages, salaries, tips, etc 11,754. 11,754.
17 Net self-employment loss
18 Alimony received
19 Nontaxable combat pay
20 Foreign earned income exclusion
21 Keogh, SEP or SIMPLE deduction
22 Combine lines 15 through 21. To IRA Wks, ln 2 11,754. 11,754.

Part IV ' Schedule 8812 and Child Tax Credit Line 11 Worksheet Computations

23 Self-employed, church and statutory employees

24 Wages, salaries, tips, etc 11,754. 11,754.
25 Nontaxable combat pay
26 Combine lines 23 through 25. To Schedule
8812, line 4a & Line 11 Wks, line 2 11,754. 11,754.
 Form 4952 Investment Interest Expense Worksheet 2016
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Investment Interest Expense ( Form 4952, line 1)

1 Investment interest expense, from Schedule K-1 1
2 Investment interest expense from royalties 2
3 Other investment interest expense:
a 3a
b b
c c
d d
4 Total investment interest expense. Add lines 1 through 3. 4

Gross Income from Property Held for Investment (Form 4952, line 4a)
5 Taxable investment income:
a From Schedule B, Interest and Dividend Income 5a
b From Schedules K-1, Partnerships, S Corporations, Estates and Trusts b
c From Form 8814, Parents’ Election to Report Child’s Interest and Dividends c
d Total d
6 Royalty income, from Schedule E 6
7 Net passive income from publicly traded partnerships 7
8 Income from nonpassive trade or business without material participation 8
9 Other investment income:
a 9a
b b
c c
d d
10 Total investment income. Add lines 5d through 9. 10

Net Capital Gain Income (Form 4952, lines 4d and 4e)

Regular Tax Alt Min Tax

11 a Net gains from Schedule D, line 16 11 a

b Less net gains from property not held for investment b
c Net gains from property held for investment. c

12 a Net capital gains from Schedule D, lesser of ln 15 or ln 16 12 a

b Less net capital gains from property not held for investment b
c Net capital gains from property held for investment. c

Investment Expenses (Form 4952, line 5)

13 Royalty expenses 13
14 Investment expenses included as itemized deductions (after the 2% limitation) 14
15 Investment expenses included as itemized deductions (no 2% limitation) 15
16 Expenses from nonpassive trade or business without material participation 16
17 Other investment expenses:
a 17 a
b b
c c
d d
18 Total investment expenses. Add lines 13 through 17. 18

Allocation of Investment Interest Expense (Schedule A, line 14)

Regular Tax Alt Min Tax

19 Allowed investment interest expense, Form 4952, line 8 19

20 Less amount deducted on other forms and schedules: 20
a Deducted on Schedule E, page 2 for passthru entities a
b Deducted on Schedule E, page 1 for royalties b
c Other amounts deducted on other forms and schedules c
d Total amount deducted on other forms and schedules d
21 Investment interest expense. 21
 Form 1040 Earned Income Credit Worksheet 2016
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QuickZoom to Schedule EIC

QuickZoom to Dependent Information Worksheet to enter qualifying children information
QuickZoom to Wages, Salaries, & Tips Worksheet to enter earned and non-earned income
QuickZoom to page 2 of this worksheet, if credit is not calculated on line 7

1 Enter the amount from Form 1040 or 1040A, line 7, or Form 1040EZ, line 1,
less amounts considered not earned for EIC purposes 1 11,754.
2 Adjustments to line 1 amount:
a Income reported as wages and as self-employment income 2a
b Other income entered as wages that is not considered earned income b
c Distributions from section 457 and other nonqualified plans reported on W-2 c
3 Subtract lines 2a, 2b and 2c from line 1 3 11,754.
4a Taxpayer’s nontaxable combat pay election for EIC 4a
b Spouse’s nontaxable combat pay election for EIC b
c Total nontaxable combat pay election 4c
5 If you were self-employed or used Schedule C or Schedule C-EZ
as a statutory employee, enter the amount from the
Earned Income Worksheet, line 4 5
6 Earned income. Add lines 3, 4c, and 5 6 11,754.
7 Enter the credit, from the EIC Table, for the amount on line 6. Be sure to use
the correct column for filing status and number of children 7 4,710.

If line 7 is zero, stop. You cannot take the credit.

Enter "No" on the dotted line next to Form 1040, line 66a.

8 Enter your AGI from Form 1040, line 38 8 11,754.

9 If you have:
? No qualifying children, is the amount on line 8 less than $8,300
($13,850 if married filing jointly)?
? 1 or more qualifying children, is the amount on line 8 less than $18,200
($23,750 if married filing jointly)?

X Yes. Go to line 10 now.

No. Enter the credit, from the EIC Table, for the amount on line 8. Be
sure to use the correct column for filing status and number of children 9
10 Earned income credit.
? If ’Yes’ on line 9, enter the amount from line 7
? If ’No’ on line 9, enter the smaller of line 7 or line 9 10 4,710.

Enter line 10 amount on Form 1040, line 66a, Form 1040A, line 42a, or Form 1040EZ, line 8a.
LaQuana E Chappelle 072-72-7356 Page 3

Compliance and Due Diligence Information

1 Is this how long your dependents lived with you in the U.S in 2016?

Yes, all of the above is correct.

No, I’ll go back and review my dependent information.
The IRS may ask you for documents to prove you lived with anyone you’re claiming for the Earned
Income Credit.

Is this where you lived with your dependents the longest in 2016?

2 Yes, my dependents lived with me at this address.

No, I’d like to add an additional address where I lived with my dependents. Use the Interview to
add an additional address where you lived with your dependents the longest in 2016.

Compliance and Due Diligence Indicator X

Disqualified from Earned Income Credit Yes X No

Potential qualifying child count 2

Non dependent potential qualifying child count 0
Qualifying child count (max 3) 2
 Form 6251 Schedule D Tax Worksheet 2016
Line 37 as refigured for the
Alternative Minimum Tax
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(a) (b) (c)

Before Allocation of After
Allocation of Capital Gain Allocation of
Capital Gain Excess * Capital Gain
Excess * Excess

1 Not applicable
2 Enter your total qualified dividends as refigured for
the Alternative Minimum Tax (AMT):
a Total qualified dividends
b Adjustment from Schedules K-1
c Other adjustments to qualified dividends
d Total. Combine lines 2a, 2b, and 2c 0. 0.
3 Enter the amount from Form 4952 for AMT, line 4g
4 Enter the amount from Form 4952 for AMT, line 4e
5 Subtract line 4 from line 3. If zero or less, enter -0- 0. 0.
6 Subtract line 5 from line 2. If zero or less, enter -0- 0. 0.
7 Net long-term capital gain:
a Enter the gain from line 15 of Schedule D
as refigured for the AMT 0.
b Enter the gain from line 16 of Schedule D
as refigured for the AMT 0.
c Enter the smaller of line 7a or line 7b 0. 0.
8 Enter the smaller of line 3 or line 4
9 Subtract line 8 from line 7c. If zero or less, enter -0- 0. 0. 0.
10 Add lines 6 and 9 0. 0.
A Enter the amount from Form 6251, line 30. 0.
B Capital gain excess. Subtract line A from line 10. * 0.
11 Total 28% rate and unrecaptured section 1250 gain:
a Enter the gain from line 18 of Schedule D
as refigured for the AMT 0.
b Enter the gain from line 19 of Schedule D
as refigured for the AMT
c Add lines 11a and 11b 0.
12 Enter the smaller of line 9 or line 11c 0.
13 Subtract line 12 from line 10. Also enter this amount
on Form 6251, line 37. 0.

* Capital gain excess applies only if filing Form 2555, Foreign Earned Income.
 Form 6251 Alternative Minimum Tax Worksheet 2016
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Taxable Income ' Line 1

1 If filing Schedule A (Form 1040), enter the amount from Form 1040, line 41.
Otherwise, enter the amount from Form 1040, line 38. (If less than zero,
enter as a negative amount.) 1 11,754.
2 Additions to income 2
3 Add lines 1 and 2 3 11,754.
4 Subtractions from income 4
5 Subtract line 4 from line 3. Enter on Form 6251, line 1 5 11,754.

Taxes ' Line 3

1 Generation skipping transfer taxes included on Schedule A, line 8 1

Home Mortgage Interest Adjustment ' Line 4

(a) (b) (c)
NOT Total
Deductible Deductible Home
for AMT for AMT Mortgage
Purposes Purposes Interest

1 Attributable to mortgage used to purchase, build, or

improve:
a Main home or second home that is house, apartment,
condominium or non-transient mobile home
b Second home that is transient mobile home or boat
c Total
2 Attributable to mortgage used to refinance:
a To pay off mortgage
b For other purposes
c Total
3 Attributable to other mortgage deductible for AMT:
a Pre-July 1, 1982 mortgage

4 Total column (a)

5 Total column (b). Enter result on Form 6251, line 4.
6 Total mortgage interest from Schedule A

Refund of Taxes ' Line 7

1 Taxable refund of state and local income tax 1
2 Amount and description of any refund of state and local personal property
taxes, foreign income or real property taxes deducted after 1986 2
3 Total tax refund adjustment. Enter on Form 6251, line 7 3

Alternative Tax Net Operating Loss Deduction (ATNOLD) ' Line 11

1 Alternative minimum taxable income (AMTI) without ATNOLD 1 11,754.

2 Enter adjustments 2
3 Adjustment for domestic production activities deduction 3
4 Adjusted AMTI without ATNOLD. Add lines 1-3 4 11,754.
5 ATNOLD limitation. Multiply line 4 by 90% 5 10,579.
6 Enter ATNOL carried to 2015 from other year(s) 6
7 Enter ATNOL included above attributable to qualified disaster losses 7
8 ATNOL above not attributable to qualified disaster losses. Line 6 minus 7 8
9 ATNOL deduction other than qualified disaster losses. Lesser of line 5 or 8 9
10 ATNOL Disaster Deduction. Lesser of line 7 or (line 4 minus line 9) 10
11 ATNOLD. Add lines 9 and 10. Enter on Form 6251, line 11, as neg 11

Incentive Stock Options ' Line 14

1 Incentive stock options adjustment from Schedule K-1 worksheets 1

2 Incentive stock options from Employer Stock Transaction Worksheets 2
3 Incentive stock options from Exercise of Stock Options Worksheets 3
4 Other incentive stock options 4
5 Total incentive stock options. Enter on Form 6251, line 14 5
LaQuana E Chappelle 072-72-7356 Page 3
Alternative Minimum Taxable Income ' Line 28

If married filing separately and Form 6251, line 28, is more than $247,450:
1 Alternative minimum taxable income, Form 6251 1
2 Threshold amount 2
3 Subtract line 2 from line 1 3
4 Multiply line 3 by 25% (.25) 4
5 Smaller of line 4 or $41,900 5
6 Add line 1 and line 5. Enter on Form 6251, line 28 6

Exemption ' Line 29

1 Enter $53,900 if single or head of household, $83,800 if married filing jointly

or qualifying widow(er), $41,900 if married filing separately 1 53,900.
2 Enter your alternative minimum taxable income from Form 6251, line 28 2 11,754.
3 Enter $119,700 if single or head of household, $159,700 if married filing
jointly or qualifying widow(er), $79,850 if married filing separately 3 119,700.
4 Subtract line 3 from line 2. If zero or less, enter -0- 4 0.
5 Multiply line 4 by 25% (.25) 5 0.
6 Subtract line 5 from line 1. If zero or less, enter -0- 6 53,900.
If any of the three conditions under Certain Children Under Age 24 apply, go
to line 7. Otherwise, enter this amount on Form 6251, line 29.
7 Minimum exemption amount for certain children under age 24 7
8 a Enter the child’s earned income, if any 8a
b Enter any adjustments b
9 Add lines 7, 8a and 8b. If zero or less, enter -0- 9
10 Enter the smaller of line 6 or line 9 here and on Form 6251, line 29. 10
 Form 6251 Foreign Earned Income 2016
Line 31 Alternative Minimum Tax Worksheet
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1 Enter amount from Form 6251, line 30 1

2 a Enter amount from Form(s) 2555, lines 45 and 50 2a
b Enter the total amount of any itemized deductions or exclusions you could not
claim because they are related to excluded income 2b
c Subtract line 2b from line 2a. If zero or less, enter 0 2c
3 Add line 1 and line 2c. Enter the result here and on Form 6251 line 36 3
4 Tax on amount on line 3
? If you reported capital gain distributions directly on Form 1040, line 13; or
you reported qualified dividends on Form 1040, line 9b; or you had a gain
on both line 15 and 16 of Schedule D (Form 1040), enter the amount from
line 3 of this worksheet on Form 6251, line 36. Complete the rest of Part III
of Form 6251. However, before completing Part III, see Form 2555 to see
if you must complete Part III with certain modifications. Then enter the
amount from Form 6251, line 64 here.
? All Others: If line 3 is $186,300 or less ($93,150 or less if married filing
separately), multiply line 3 by 26% (.26). Otherwise, multiply line 3 by 28%
(.28) and subtract $3,726 ($1,863 if married filing separately) from
the result. 4
5 Tax on amount on line 2c. If line 2c is $186,300 or less ($93,150 or less if
married filing separately), multiply line 2c by 26% (.26). Otherwise, multiply
line 2c by 28% (.28) and subtract $3,726 ($1,863 if married filing separately)
from the result 5
6 Subtract line 5 from line 4. Enter here and on Form 6251, line 31. If zero or
less, enter 0 6
 Federal Carryover Worksheet 2016
G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

2015 State and Local Income Tax Information (See Tax Help)

(a) (b) (c) (d) (e) (f) (g)

State or Paid With Estimates Pd Total With- Paid With Total Over- Applied
Local ID Extension After 12/31 held/Pmts Return payment Amount

Totals

Other Tax and Income Information 2015 2016

1 Filing status 1 4 HH
2 Number of exemptions for blind or over 65 (0 - 4) 2
3 Itemized deductions 3 724.
4 Check box if required to itemize deductions 4
5 Adjusted gross income 5 11,754.
6 Tax liability for Form 2210 or Form 2210-F 6 0.
7 Alternative minimum tax 7
8 Federal overpayment applied to next year estimated tax 8

QuickZoom to the IRA Information Worksheet for IRA information

Excess Contributions 2015 2016

9a Taxpayer’s excess Archer MSA contributions as of 12/31 9a

b Spouse’s excess Archer MSA contributions as of 12/31 b
10 a Taxpayer’s excess Coverdell ESA contributions as of 12/31 10 a
b Spouse’s excess Coverdell ESA contributions as of 12/31 b
11 a Taxpayer’s excess HSA contributions as of 12/31 11 a
b Spouse’s excess HSA contributions as of 12/31 b

Loss and Expense Carryovers 2015 2016

Note: Enter all entries as a positive amount

12 a Short-term capital loss 12 a

b AMT Short-term capital loss b
13 a Long-term capital loss 13 a
b AMT Long-term capital loss b
14 a Net operating loss available to carry forward 14 a
b AMT Net operating loss available to carry forward b
15 a Investment interest expense disallowed 15 a
b AMT Investment interest expense disallowed b
16 Nonrecaptured net Section 1231 losses from: a 2016 16 a
b 2015 b
c 2014 c
d 2013 d
e 2012 e
f 2011 f
 Form 8582 Modified Adjusted Gross Income Worksheet 2016
Line 7 G Keep for your records

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle 072-72-7356

Description Amount

Income

Wages 11,754.
Interest income before Series EE bond exclusion
Dividend income
Tax refund
Alimony received
Nonpassive business income or loss
Royalty and nonpassive rental activities income or loss
Nonpassive partnership income or loss
Nonpassive S corporation income or loss
Nonpassive farm rental income or loss
Nonpassive farm income or loss
Nonpassive estate and trust income or loss
Real estate mortgage investment conduits
Business gains and losses from nonpassive activities
Capital gains and losses
Taxable IRA distributions
Taxable pension distributions
Unemployment compensation
Other income

Total income 11,754.

Adjustments

Educator expenses
Certain business expenses of reservists, performing artists, and government officials
Health savings account deduction
Moving expenses
Self-employed SEP, SIMPLE, and qualified plans
Self-employed health insurance deduction
Penalty on early withdrawals of savings
Alimony paid
Other adjustments

Total adjustments

Modified adjusted gross income 11,754.

 Two-Year Comparison 2016

Name(s) Shown on Return Social Security Number

LaQuana E Chappelle

Income 2015 2016 Difference %

Wages, salaries, tips, etc 11,754. 11,754.

Interest and dividend income
State tax refund
Business income (loss)
Capital and other gains (losses)
IRA distributions
Pensions and annuities
Rents and royalties
Partnerships, S Corps, etc
Farm income (loss)
Social security benefits
Income other than the above
Total Income 11,754. 11,754.
Adjustments to Income
Adjusted Gross Income 11,754. 11,754.

Itemized Deductions
Medical and dental
Income or sales tax 724. 724.
Real estate taxes
Personal property and other taxes
Interest paid
Gifts to charity
Casualty and theft losses
Miscellaneous
Phaseout of itemized deductions
Total Itemized Deductions 724. 724.
Standard or Itemized Deduction 9,300. 9,300.
Exemption Amount 12,150. 12,150.

Taxable Income 0. 0.

Income tax 0. 0.
Additional income taxes
Alternative minimum tax
Total Income Taxes 0. 0.
Nonbusiness credits 0. 0.
Business credits
Total Credits 0. 0.
Self-employment tax
Other taxes 0. 0.
Total Tax After Credits 0. 0.
Withholding 1,148. 1,148.
Estimated and extension payments
Earned income credit 4,710. 4,710.
Additional child tax credit 1,313. 1,313.
Other payments
Total Payments 7,171. 7,171.
Form 2210 penalty
Applied to next year’s estimated tax
Refund 7,171. 7,171.
Balance Due

Current year effective tax rate -51.24 %

 Tax Summary 2016
G Keep for your records

Name (s)
LaQuana E Chappelle

Total income 11,754.

Adjustments to income
Adjusted gross income 11,754.
Itemized/standard deduction 9,300.
Exemption amount 12,150.
Taxable income 0.
Tentative tax 0.
Additional taxes
Alternative minimum tax
Total credits 0.
Other taxes 0.
Total tax 0.
Total payments 7,171.
Estimated tax penalty
Amount Overpaid 7,171.
Refund 7,171.
Amount Applied to Estimate
Balance due 0.

Which Form 1040 to file?

You must use Form 1040A or Form 1040 because
your filing status is head of household.
 Compare to U. S. Averages 2016
G Keep for your records

Name(s) Shown on Return Social Security No

LaQuana E Chappelle 072-72-7356

Your 2016 adjusted gross income (AGI) 11,754.

National adjusted gross income range used below from 0. to 14,999.

Note: National average amounts have been adjusted for inflation. See Help for details.

Actual National
Selected Income, Deductions, and Credits Per Return Average

Salaries and wages 11,754. 8,413.

Taxable interest 956.
Tax-exempt interest 5,790.
Dividends 2,248.
Business net income 7,725.
Business net loss 26,063.
Net capital gain 8,052.
Net capital loss 2,376.
Taxable IRA 5,266.
Taxable pensions and annuities 6,811.
Rent and royalty net income 7,629.
Rent and royalty net loss 14,607.
Partnership and S corporation net income 21,356.
Partnership and S corporation net loss 90,515.
Taxable social security benefits 2,448.

Medical and dental expenses deduction 8,875.

Taxes paid deduction 724. 3,602.
Interest paid deduction 7,200.
Charitable contributions deduction 1,441.
Total itemized deductions 724. 15,717.

Child care credit 0. 83.

Education tax credits 241.
Child tax credit 0. 153.
Retirement savings contributions credit 159.
Earned income credit 4,710. 1,904.

Other Information Actual National

Per Return Average

Adjusted gross income 11,754. 2,535.

Taxable income 0. 2,623.
Income tax 0. 291.
Alternative minimum tax 15,803.
Total tax liability 0. 496.
 CUSTOMER SERVICE: 877-908-7228

Santa Barbara Tax Products Group LLC

and Green Dot Bank Refund Processing Agreement ("Agreement")

Name
Social Security No.

This Agreement contains important terms, conditions and disclosures about the processing of your refund
(the "Refund Processing Service") by Santa Barbara Tax Products Group, LLC ("Processor"), a third party
processor using banking services of Green Dot Bank ("Bank"). Read this Agreement carefully before
accepting its terms and conditions, and print a copy and/or retain this information electronically for future
reference. As used in this Agreement, the words "you" and "your" refer to the applicant or both the applicant
and joint applicant if the 2016 federal income tax return is a joint return (individually and collectively,
"Applicant"). The words "we," "us" and "our" refer to Bank and Processor.

1. NOTICE: No Requirement To Use the Refund Processing Service In Order To File Electronically.
YOU UNDERSTAND THAT A REFUND PROCESSING FEE OF $ ("REFUND PROCESSING FEE") IS
CHARGED BY PROCESSOR TO ESTABLISH A TEMPORARY ACCOUNT TO RECEIVE YOUR FEDERAL TAX
REFUND, TO PROCESS IT, TO DEDUCT YOUR TURBOTAX FEES AND OTHER AUTHORIZED FEES FROM
THAT ACCOUNT, AND TO FORWARD FUNDS TO YOU. THE REFUND PROCESSING FEE IS NOT A LOAN; IT
IS DUE TO PROCESSOR WHETHER OR NOT THE FEDERAL TAX REFUND OCCURS BUT PROCESSOR WILL
NOT PURSUE COLLECTION OF THE REFUND PROCESSING FEE IF YOUR FEDERAL TAX REFUND DOES
NOT OCCUR. THIS FEE IS COLLECTED ONLY AT THE TIME THE REFUND OCCURS. YOU CAN AVOID THIS
FEE AND NOT USE THE REFUND PROCESSING SERVICE BY INSTEAD PAYING THE APPLICABLE
TURBOTAX FEES TO INTUIT BY CREDIT OR DEBIT CARD AT THE TIME YOU FILE YOUR 2016 FEDERAL
INCOME TAX RETURN AND ELECTING TO HAVE YOUR REFUND DIRECTLY DEPOSITED IN YOUR OWN
BANK ACCOUNT OR MAILED TO YOU. IF YOU DO USE THE REFUND PROCESSING SERVICE, YOU CAN
EXPECT TO RECEIVE THE PROCEEDS FROM YOUR FEDERAL TAX REFUND WITHIN 21 DAYS FROM WHEN
THE INTERNAL REVENUE SERVICE ("IRS") ACCEPTS YOUR RETURN UNLESS THERE ARE PROCESSING
DELAYS BY THE IRS (OR UNLESS YOUR RETURN CONTAINS EARNED INCOME TAX CREDIT OR
ADDITIONAL CHILD TAX CREDIT, IN WHICH CASE THE IRS WILL ISSUE YOUR REFUND NO EARLIER THAN
FEBRUARY 15, 2017). THE REFUND PROCESSING SERVICE WILL NEITHER SPEED UP NOR DELAY YOUR
FEDERAL TAX REFUND. THE COST OF PREPARING YOUR TAX RETURN IS NOT ANY MORE OR LESS IF
YOU PURCHASE THE REFUND PROCESSING SERVICE.

2. Authorization to Release Personal Information. You authorize the IRS to disclose any information to
Bank and Processor related to the funding of your 2016 federal tax refund. You also authorize Intuit, as the
transmitter of your electronically filed tax return, to disclose your tax return and contact information to Bank
and Processor for use in connection with the refund processing services being provided pursuant to this
Agreement and Bank and Processor to share your information with Intuit. None of Intuit, Bank or Processor
will disclose or use your tax return information for any other purpose, except as permitted by law. Bank and
Processor will not use your tax information or contact information for any marketing purpose. Please see the
Privacy Policy at the end of this Agreement describing how Bank may use or share your personal
information.

3. Summary of Terms
Expected Federal Refund $
Less Processor Refund Processing Fee $
Less TurboTax Fees $
Less Additional Products and Services Purchased $
Expected Proceeds* $
* These charges are itemized. This is only an estimate. The amount will be reduced by any applicable sales taxes, and if
applicable, a Return Item Fee and an Account Research and Processing Fee paid to Processor as set forth in Sections 4, 6 and
7 below.

4. Temporary Deposit Account Authorization. You hereby authorize Bank to establish a temporary deposit
account ("Deposit Account") for the purpose of receiving your tax year 2016 federal tax refund from the IRS.
Bank or Processor must receive an acknowledgement from the IRS that your return has been electronically
filed and accepted for processing before the Deposit Account can be opened. You authorize Processor to
deduct from your Deposit Account the following amounts: (i) the Refund Processing Fee; (ii) the fees and
charges related to the preparation, processing and transmission of your tax return ("TurboTax Fees"); and
(iii) fees for Additional Products and Services Purchased, plus applicable taxes. You also authorize Bank to
deduct twenty dollars ($20.00) as a returned item processing fee (the "Return Item Fee") from your Deposit
Account for the additional processing required in the event that your deposit is returned or cannot be
delivered as directed in Section 7 below. A fee of $25.00 (the "Account Research and Processing Fee") may
be charged if we are required to provide additional processing to return the funds to the IRS. These fees will
 Page 2

be deducted from the Deposit Account and will be retained by Processor. You authorize Bank and Processor
to disburse the balance of the Deposit Account to you after making all authorized deductions or payments. If
the Deposit Account does not have sufficient funds to pay the TurboTax Fees and the fees for Additional
Products and Services Purchased as set forth in Section 3, (a) you authorize Bank and/or Processor to
automatically deduct such fees (or any portion thereof) via ACH, electronic check, or wire transfer directly
from the account into which you authorized Bank to deposit your Expected Proceeds as set forth in Section
7, and (b) if you made alternative arrangements with TurboTax for payment of such fees, those
arrangements will be attempted prior to any automatic deduction.
5. Acknowledgements. (a) You understand that: (i) neither Bank nor Processor can guarantee the amount
of your tax year 2016 federal tax refund or the date it will be issued, and (ii) neither Bank nor Processor is
affiliated with the transmitter of the tax return (Intuit) and neither warrants the accuracy of the software
used to prepare the tax return. (b) You agree that Intuit is not acting as your agent and is not under any
fiduciary duty with respect to the processing of your refund by Bank and Processor. (c) Your refund may
be held or returned to the IRS if it is suspected of fraud or identity theft.

6. Truth in Savings Disclosure. The Deposit Account is being opened for the purpose of receiving your (or
both spouses if this is a jointly filed return) tax year 2016 federal tax refund. Processor and Bank will deduct
from the Deposit Account the fees set forth in Section 3, including the Refund Processing Fee for
opening and maintaining the Deposit Account and processing your tax refund. No other deposits may be
made to the Deposit Account. No withdrawals will be allowed from the Deposit Account except to collect the
fees stated in this Section, Section 3, Section 7, and as provided in Section 4. No interest is payable on the
deposit; thus, the annual percentage yield and interest rate are 0%. The Deposit Account will be closed after
all authorized deductions have been made and any remaining balance has been disbursed to you. We will
also charge a Return Item Fee of $20.00 if the refund cannot be delivered as directed in Section 7 of this
Agreement. A $25.00 Account Research and Processing Fee may be charged if we are required to provide
additional processing to return the funds to the IRS. These fees will be deducted from the Deposit Account
and will be retained by Processor. Questions or concerns about the Deposit Account should be directed to
Santa Barbara Tax Products, Group, LLC, 11085 North Torrey Pines Road, Suite 210, La Jolla, CA 92037 or
via the Internet at [Link]

7. Disbursement Methods: You agree that the disbursement method selected below will be used by Bank
and Processor to disburse funds to you.
a) Direct Deposit to Prepaid Debit Card: If you choose this option, you authorize Bank and
Processor to transfer the balance of your Deposit Account to the financial institution that supports your
prepaid debit card, so that the financial institution may deposit the balance of your refund, as directed
by you, on the respective prepaid debit card you have selected. Additional fees may be charged for
the use of the card. Please review the cardholder agreement associated with the use of your prepaid
debit card provided by the participating financial institution to learn of other fees, charges, terms and
conditions that will apply. Neither Bank nor Processor will be responsible for your funds once they
have been deposited with the respective financial institution.

b) Direct Deposit to Checking or Savings Account: If you choose this option, the balance of your
Deposit Account will be disbursed to you electronically by ACH direct deposit to your personal bank
account designated below. If a joint return is filed, the bank account may be a joint account or the
individual account of either spouse.

DIRECT DEPOSIT ACCOUNT TYPE:

Checking
Savings
RTN #
Account #
Note: To ensure that there are no delays in receiving your refund, please contact your financial
institution to confirm that you are using the correct RTN (routing) and account number. If you or your
representative enter your account information incorrectly and your deposit is returned to Bank, the
Deposit Account balance minus a $20.00 Return Item Fee will be disbursed to you via a cashier’s
check mailed to your physical address of record. Bank, Processor and Intuit are not responsible for the
misapplication of a direct deposit that results from error, negligence or malfeasance on the part of you
or your representative. In cases where Bank has received your federal tax refund but is unable to
deliver the funds directly to you, funds may be held at Bank until claimed, or returned to the IRS. An
Account Research and Processing Fee of $25.00 may be charged if we are required to provide
additional processing to return the funds to the IRS. Return Item and Account Research and
Processing Fees will not exceed $45.00 in the aggregate, and will be deducted from the Deposit
Account for federal tax refunds that continue to be undeliverable and unclaimed and must be returned
to the IRS. These fees will be retained by Processor.
 Page 3

You must notify Bank in writing 3 business days prior to the account being debited to revoke the
authorization for applicable fees agreed to in Section 4, and to afford Bank a reasonable opportunity
to act on your request. You may notify us in writing at: Green Dot Bank, c/o Santa Barbara Tax
Products Group, LLC, 11085 North Torrey Pines Road, Suite 210, La Jolla, California 92037.

8. FEDERAL ELECTRONIC FUND TRANSFER ACT DISCLOSURES: In case of errors or questions about
electronic transfers to or from the Deposit Account, write to Santa Barbara Tax Products, Group, LLC, 11085
North Torrey Pines Road, Suite 210, La Jolla, California 92037 or telephone (877) 908-7228 and provide
your name, a description or explanation of the error, and the dollar amount of the suspected error. We will
determine whether an error occurred within 10 business days after we hear from you and will correct any
error promptly. If we need more time, however, we may take up to 45 days to investigate your complaint or
question. If we decide to do this, we will credit your Deposit Account within 10 business days for the amount
you think is in error, so that you will have the use of the money during the time it takes us to complete our
investigation. If we ask you to put your complaint or question in writing and we do not receive it within 10
business days, we may not credit your Deposit Account. For errors involving transfers of funds to or from the
Deposit Account within 30 days after the first deposit to the Deposit Account was made, (i) we may take up
to 90 days to investigate your complaint or question, and (ii) we may take up to 20 business days to credit
your Deposit Account for the amount you think is in error. We will tell you the results within three business
days after completing our investigation. If we decide that there was no error, we will send you a written
explanation. You may ask for copies of the documents that we used in our investigation.

Business Days: Our business days are Monday through Friday, excluding federal holidays. Saturday,
Sunday, and federal holidays are not considered business days, even if we are open.

Confidentiality: We will disclose information to third parties about your account or the transfers you make:

? To complete transfers as necessary;

? To verify the existence and condition of your account upon the request of a third party, such as a credit
bureau or merchant;
? To comply with government agency or court orders;
? If you give us your written permission; or
? As explained in the Privacy Policy following this Agreement.

Our Liability: If we do not complete a transfer to your account on time or in the correct amount according to
this Agreement, we may be liable for your losses or damages. In addition to all other limitations of liability
set forth in this Agreement, we will not be liable to you if, among other things:
? Circumstances beyond our control (natural disasters, such as fire or flood) prevent the transfer, despite
reasonable precautions that have been taken.
? The funds in your account are subject to legal process or other claim restricting such transfer.
? You or your representative provide us with inaccurate information.

9. Compensation. In addition to any fees paid directly by you to Intuit, Processor will pay compensation to
Intuit in consideration of Intuit’s provision of various programming, testing, data processing, transmission,
systems maintenance, status reporting and other software, technical and communications services. The
Refund Processing Fee will be retained by Processor for its refund processing services. Processor shall pay
Bank for its banking services.

10. Governing Law. The enforcement and interpretation of this Agreement and the transactions
contemplated herein shall be governed by the laws of the United States, including the Electronic Signatures
in Global and National Commerce Act, and, to the extent state law applies, the substantive law of Ohio.
 Page 4

11. Arbitration Provision. This arbitration provision is made pursuant to a transaction involving interstate
commerce and shall be governed by the Federal Arbitration Act. You agree that any and all disputes which
in any way arise out of or relate to this Agreement, shall be resolved solely by binding arbitration before the
American Arbitration Association ("AAA") before a single arbitrator in arbitration commenced as close as
possible to where you reside. Any and all disputes must be brought in the parties’ individual capacity, and
not as a plaintiff or class member in any purported class or representative proceeding. Judgment on the
award rendered by the arbitrator may be entered in any court having jurisdiction over the dispute. Each party
to any such arbitration shall bear its own separate costs and expenses of the arbitration and shall share
equally in the charges of the AAA, including the fee of the arbitrator. However, if you are unable to pay any
fee of the AAA or the arbitrator, we agree to pay those fees for you. By agreeing to arbitration, you and we
are waiving our rights to file a lawsuit and proceed in court and to have a jury trial to resolve disputes. The
word "disputes" is given its broadest possible meaning, and includes all claims; disputes or controversies,
including without limitation any claim or attempt to set aside this arbitration provision. You may choose to
opt-out of this arbitration provision but only by following the process set forth below. If you do not wish to
be subject to this arbitration provision, then you must notify us in writing within sixty (60) calendar days of
the date of this Agreement at the following address: Santa Barbara Tax Products Group, LLC, 11085 North
Torrey Pines Road, Suite 210, La Jolla, CA 92037, Attn. Arbitration Opt-Out. Your written notice must
include your name, address, Social Security Number, the date of this Agreement, and a statement that you
wish to opt out of the arbitration provision. If you choose to opt out, then your choice will apply only to this
Agreement.

12. Customer Identity Validation Disclosure: To help Bank, Processor and the government identify and fight
tax refund fraud, as well as fight the funding of terrorism and money laundering activities, Bank and
Processor obtain, verify, and record information that identifies each Refund Processing Service client. What
this means for you: When you apply to use the Refund Processing Service for the purpose of receiving your
federal tax refund, we will ask for your name, address, date of birth, and other information that will allow us
to identify you. We may also ask to see your driver’s license or other identifying documents if we need to
perform additional due diligence on your account.

YOUR AGREEMENT

Bank and Processor agree to all of the terms of this Agreement. By selecting the "I Agree" button in
TurboTax: (i) You authorize Bank to receive your 2016 federal tax refund from the IRS and Processor to
make the deductions from your refund described in the Agreement, (ii) You agree to receive all
communications electronically in accordance with the "Communications" section of the Tax Year 2016
TurboTaxfi User Agreement, (iii) You consent to the release of your 2016 federal tax refund deposit
information and application information as described in Section 2 of this Agreement; and (iv) You
acknowledge that you have reviewed, and agree to be bound by, the Agreement’s terms and conditions. If
this is a joint return, selecting "I Agree" indicates that both spouses agree to be bound by the terms and
conditions of the Agreement.
 Rev. 10/2016

Green Dot Bank’s Privacy Policy

FACTS WHAT DOES GREEN DOT BANK DO WITH YOUR PERSONAL INFORMATION?

Why? Financial companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you how
we collect, share, and protect your personal information. Please read this notice carefully to
understand what we do.

What? The types of personal information that we collect and share depend on the product or service
you have with us. This can include:

? Social Security number and account balances

? account transactions and purchase history
? transaction history and overdraft history

When you are no longer our customer, we continue to share your information as described in
this notice.

How? All financial companies need to share customers’ personal information to run their everyday
business. In the section below, we list the reasons financial companies can share their
customers’ personal information; the reasons Green Dot Bank chooses to share; and whether you
can limit this sharing.

Reasons we can share your Does Green Dot Bank Can you limit this sharing?
personal information Share?

For our everyday business purposes '

such as to process your transactions,
maintain your account(s), respond to court Yes No
orders and legal investigations, or report to
credit bureaus.

For our marketing purposes ' No We don’t share

to offer our products and services to you.

For joint marketing with other No We don’t share

financial companies.

For our affiliates’ everyday

business purposes ' Yes No
information about your transactions
and experiences.

For our affiliates’ everyday

business purposes ' No We don’t share
information about your creditworthiness.

For our affiliates to market to you. No We don’t share

For nonaffiliates to market to you. No We don’t share

Questions? Call 1-866-795-7597 or go to [Link]

 Page 2

Page 2

What we do

How does Green Dot Bank To protect your personal information from unauthorized access
protect my and use, we use security measures that comply with federal law.
personal information? These measures include computer safeguards and secured files
and buildings.

How does Green Dot We collect your personal information, for example, when you
collect my
personal information? ? open an account or make deposits or withdrawals from your
account
? use your debit card or provide account information
? give us your contact information

We also collect your personal information from others, such as

credit bureaus, affiliates, or other companies.

Why can’t I limit all sharing? Federal law gives you the right to limit only

? Sharing for affiliates’ everyday business purposes ' information

about your creditworthiness
? Affiliates from using your information to market to you
? Sharing for non affiliates to market to you.

State laws and individual companies may give you additional rights
to limit sharing.
See below for more on your rights under state law.

Definitions

Affiliates Companies related by common ownership or control. They can be

financial and nonfinancial companies.

? Our affiliates include companies with a common corporate

identity of Green Dot (such as our parent bank holding company
Green Dot Corporation), financial companies such as
AccountNow, Inc. and tax processing services companies such
as Santa Barbara Tax Products Group, LLC.

Nonaffiliates Companies not related by common ownership or control. They can

be financial or nonfinancial companies.

? Green Dot Bank does not share with non

affiliates so they can market to you.

Joint marketing A formal joint marketing agreement between nonaffiliated financial

companies that together market financial products or services
to you.

? Green Dot Bank does not jointly market

Other important information

Depending on where you live, you may have additional privacy protections under state law. We will comply
with applicable state laws before sharing nonpublic personal information about you. We may do this by
sending a separate notice of those rights to you. For example, if you are a resident of California or Vermont,
we will not share with nonaffiliates except for our everyday business purposes or with your consent.

[Link] 01/06/17
 CUSTOMER SERVICE: 877-908-7228
Santa Barbara Tax Products Group, LLC

and Civista Bank Refund Processing Agreement ("Agreement")

Name LaQuana E Chappelle

Social Security No. 072-72-7356

This Agreement contains important terms, conditions and disclosures about the processing of your refund
(the "Refund Processing Service") by Santa Barbara Tax Products Group, LLC ("Processor"), a third party
processor using banking services of Civista Bank ("Bank"). Read this Agreement carefully before accepting
its terms and conditions, and print a copy and/or retain this information electronically for future reference. As
used in this Agreement, the words "you" and "your" refer to the applicant or both the applicant and joint
applicant if the 2016 federal income tax return is a joint return (individually and collectively, "Applicant"). The
words "we," "us" and "our" refer to Bank and Processor.

1. NOTICE: No Requirement To Use the Refund Processing Service In Order To File Electronically.
YOU UNDERSTAND THAT A REFUND PROCESSING FEE OF $34.99 ("REFUND PROCESSING FEE") IS
CHARGED BY PROCESSOR TO ESTABLISH A TEMPORARY ACCOUNT TO RECEIVE YOUR FEDERAL TAX
REFUND, TO PROCESS IT, TO DEDUCT YOUR TURBOTAX FEES AND OTHER AUTHORIZED FEES FROM
THAT ACCOUNT, AND TO FORWARD FUNDS TO YOU. THE REFUND PROCESSING FEE IS NOT A LOAN; IT
IS DUE TO PROCESSOR WHETHER OR NOT THE FEDERAL TAX REFUND OCCURS BUT PROCESSOR WILL
NOT PURSUE COLLECTION OF THE REFUND PROCESSING FEE IF YOUR FEDERAL TAX REFUND DOES
NOT OCCUR. THIS FEE IS COLLECTED ONLY AT THE TIME THE REFUND OCCURS. YOU CAN AVOID THIS
FEE AND NOT USE THE REFUND PROCESSING SERVICE BY INSTEAD PAYING THE APPLICABLE
TURBOTAX FEES TO INTUIT BY CREDIT OR DEBIT CARD AT THE TIME YOU FILE YOUR 2016 FEDERAL
INCOME TAX RETURN AND ELECTING TO HAVE YOUR REFUND DIRECTLY DEPOSITED IN YOUR OWN
BANK ACCOUNT OR MAILED TO YOU. IF YOU DO USE THE REFUND PROCESSING SERVICE, YOU CAN
EXPECT TO RECEIVE THE PROCEEDS FROM YOUR FEDERAL TAX REFUND WITHIN 21 DAYS FROM WHEN
THE INTERNAL REVENUE SERVICE ("IRS") ACCEPTS YOUR RETURN UNLESS THERE ARE PROCESSING
DELAYS BY THE IRS (OR UNLESS YOUR RETURN CONTAINS EARNED INCOME TAX CREDIT OR
ADDITIONAL CHILD TAX CREDIT, IN WHICH CASE THE IRS WILL ISSUE YOUR REFUND NO EARLIER THAN
FEBRUARY 15, 2017). THE REFUND PROCESSING SERVICE WILL NEITHER SPEED UP NOR DELAY YOUR
FEDERAL TAX REFUND. THE COST OF PREPARING YOUR TAX RETURN IS NOT ANY MORE OR LESS IF
YOU PURCHASE THE REFUND PROCESSING SERVICE.

2. Authorization to Release Personal Information. You authorize the IRS to disclose any information to
Bank and Processor related to the funding of your 2016 federal tax refund. You also authorize Intuit, as the
transmitter of your electronically filed tax return, to disclose your tax return and contact information to Bank
and Processor for use in connection with the refund processing services being provided pursuant to this
Agreement and Bank and Processor to share your information with Intuit. None of Intuit, Bank or Processor
will disclose or use your tax return information for any other purpose, except as permitted by law. Bank and
Processor will not use your tax information or contact information for any marketing purpose. Please see the
Privacy Policy at the end of this Agreement describing how Bank may use or share your personal
information.

3. Summary of Terms
Expected Federal Refund $ 7,171.00
Less Processor Refund Processing Fee $ 34.99
Less TurboTax Fees $ 71.98
Less Additional Products and Services Purchased $
Expected Proceeds* $ 7,064.03
*These charges are itemized. This is only an estimate. The amount will be reduced by any applicable sales taxes, and if
applicable, a Return Item Fee and an Account Research and Processing Fee paid to Processor as set forth in Sections 4, 6 and
7 below.

4. Temporary Deposit Account Authorization. You hereby authorize Bank to establish a temporary deposit
account ("Deposit Account") for the purpose of receiving your tax year 2016 federal tax refund from the IRS.
Bank or Processor must receive an acknowledgement from the IRS that your return has been electronically
filed and accepted for processing before the Deposit Account can be opened. You authorize Processor to
deduct from your Deposit Account the following amounts: (i) the Refund Processing Fee; (ii) the fees and
charges related to the preparation, processing and transmission of your tax return ("TurboTax Fees"); and
(iii) fees for Additional Products and Services Purchased plus applicable taxes. You also authorize Bank to
deduct twenty dollars ($20.00) as a returned item processing fee (the "Return Item Fee") from your Deposit
Account for the additional processing required in the event that your deposit is returned or cannot be
delivered as directed in Section 7 below. A fee of $25.00 (the "Account Research and Processing Fee") may
be charged if we are required to provide additional processing to return the funds to the IRS. These fees will
be deducted from the Deposit Account and will be retained by Processor. You authorize Bank and Processor
to disburse the balance of the Deposit Account to you after making all authorized deductions or payments. If
LaQuana E Chappelle 072-72-7356 Page 2

the Deposit Account does not have sufficient funds to pay the TurboTax Fees and the fees for Additional
Products and Services Purchased as set forth in Section 3, (a) you authorize Bank and/or Processor to
automatically deduct such fees (or any portion thereof) via ACH, electronic check, or wire transfer directly
from the account into which you authorized Bank to deposit your Expected Proceeds as set forth in Section
7, and (b) if you made alternative arrangements with TurboTax for payment of such fees, those
arrangements will be attempted prior to any automatic deduction.
5. Acknowledgements. . (a) You understand that: (i) neither Bank nor Processor can guarantee the
amount of your tax year 2016 federal tax refund or the date it will be issued, and (ii) neither Bank nor
Processor is affiliated with the transmitter of the tax return (Intuit) and neither warrants the accuracy of the
software used to prepare the tax return. (b) You agree that Intuit is not acting as your agent and is not
under any fiduciary duty with respect to the processing of your refund by Bank and Processor. (c) Your
refund may be held or returned to the IRS if it is suspected of fraud or identity theft.

6. Truth in Savings Disclosure. The Deposit Account is being opened for the purpose of receiving your (or
both spouses if this is a jointly filed return) tax year 2016 federal tax refund. Processor and Bank will deduct
from the Deposit Account the fees set forth in Section 3, including the 34.99 Refund Processing Fee for
opening and maintaining the Deposit Account and processing your tax refund. No other deposits may be
made to the Deposit Account. No withdrawals will be allowed from the Deposit Account except to collect the
fees stated in this Section, Section 3, Section 7, and as provided in Section 4. No interest is payable on the
deposit; thus, the annual percentage yield and interest rate are 0%. The Deposit Account will be closed after
all authorized deductions have been made and any remaining balance has been disbursed to you. We will
also charge a Return Item Fee of $20.00 if the refund cannot be delivered as directed in Section 7 of this
Agreement. A $25.00 Account Research and Processing Fee may be charged if we are required to provide
additional processing to return the funds to the IRS. These fees will be deducted from the Deposit Account
and will be retained by Processor. Questions or concerns about the Deposit Account should be directed to
Santa Barbara Tax Products, Group, LLC, 11085 North Torrey Pines Road, Suite 210, La Jolla, CA 92037 or
via the Internet at [Link]

7. Disbursement Methods: You agree that the disbursement method selected below will be used by Bank
and Processor to disburse funds to you.
a Direct Deposit to Prepaid Debit Card: If you choose this option, you authorize Bank and
Processor to transfer the balance of your Deposit Account to the financial institution that supports your
prepaid debit card, so that the financial institution may deposit the balance of your refund, as directed
by you, on the respective prepaid debit card you have selected. Additional fees may be charged for
the use of the card. Please review the cardholder agreement associated with the use of your prepaid
debit card provided by the participating financial institution to learn of other fees, charges, terms and
conditions that will apply. Neither Bank nor Processor will be responsible for your funds once they
have been deposited with the respective financial institution.

b X Direct Deposit to Checking or Savings Account: If you choose this option, the balance of your
Deposit Account will be disbursed to you electronically by ACH direct deposit to your personal bank
account designated below. If a joint return is filed, the bank account may be a joint account or the
individual account of either spouse.

DIRECT DEPOSIT ACCOUNT TYPE:

X Checking
Savings
RTN # 026008811
Account # 6806591399
Note: To ensure that there are no delays in receiving your refund, please contact your financial
institution to confirm that you are using the correct RTN (routing) and account number. If you or your
representative enter your account information incorrectly and your deposit is returned to
Bank, the Deposit Account balance minus a $20.00 Return Item Fee will be disbursed to you via a
cashier’s check mailed to your physical address of record. Bank, Processor and Intuit are not
responsible for the misapplication of a direct deposit that results from error, negligence or malfeasance
on the part of you or your representative. In cases where Bank has received your federal tax refund
but is unable to deliver the funds directly to you, funds may be held at Bank until claimed, or returned
to the IRS. An Account Research and Processing Fee of $25.00 may be charged if we are required to
provide additional processing to return the funds to the IRS. Return Item and Account Research and
Processing Fees will not exceed $45.00 in the aggregate, and will be deducted from the Deposit
Account for federal tax refunds that continue to be undeliverable and unclaimed and must be returned
to the IRS. These fees will be retained by Processor.
LaQuana E Chappelle 072-72-7356 Page 3

You must notify Bank in writing 3 business days prior to the account being debited to revoke the
authorization for applicable fees agreed to in Section 4, and to afford Bank a reasonable opportunity
to act on your request. You may notify us in writing at: Civista Bank, c/o Santa Barbara Tax Products
Group, LLC, 11085 North Torrey Pines Road, Suite 210, La Jolla, California 92037.

8. FEDERAL ELECTRONIC FUND TRANSFER ACT DISCLOSURES: In case of errors or questions about
electronic transfers to or from the Deposit Account, write to Santa Barbara Tax Products, Group, LLC, 11085
North Torrey Pines Road, Suite 210, La Jolla, California 92037 or telephone (877) 908-7228 and provide
your name, a description or explanation of the error, and the dollar amount of the suspected error. We will
determine whether an error occurred within 10 business days after we hear from you and will correct any
error promptly. If we need more time, however, we may take up to 45 days to investigate your complaint or
question. If we decide to do this, we will credit your Deposit Account within 10 business days for the amount
you think is in error, so that you will have the use of the money during the time it takes us to complete our
investigation. If we ask you to put your complaint or question in writing and we do not receive it within 10
business days, we may not credit your Deposit Account. For errors involving transfers of funds to or from the
Deposit Account within 30 days after the first deposit to the Deposit Account was made, (i) we may take up
to 90 days to investigate your complaint or question, and (ii) we may take up to 20 business days to credit
your Deposit Account for the amount you think is in error. We will tell you the results within three business
days after completing our investigation. If we decide that there was no error, we will send you a written
explanation. You may ask for copies of the documents that we used in our investigation.

Business Days: Our business days are Monday through Friday, excluding federal holidays. Saturday,
Sunday, and federal holidays are not considered business days, even if we are open.

Confidentiality: We will disclose information to third parties about your account or the transfers you make:

? To complete transfers as necessary;

? To verify the existence and condition of your account upon the request of a third party, such as a credit
bureau or merchant;
? To comply with government agency or court orders;
? If you give us your written permission; or
? As explained in the Privacy Policy following this Agreement.

Our Liability: If we do not complete a transfer to your account on time or in the correct amount according to
this Agreement, we may be liable for your losses or damages. In addition to all other limitations of liability
set forth in this Agreement, we will not be liable to you if, among other things:
? Circumstances beyond our control (natural disasters, such as fire or flood) prevent the transfer, despite
reasonable precautions that have been taken.
? The funds in your account are subject to legal process or other claim restricting such transfer.
? You or your representative provide us with inaccurate information.

9. Compensation. In addition to any fees paid directly by you to Intuit, Processor will pay compensation to
Intuit in consideration of Intuit’s provision of various programming, testing, data processing, transmission,
systems maintenance, status reporting and other software, technical and communications services. The
Refund Processing Fee will be retained by Processor for its refund processing services. Processor shall pay
Bank for its banking services.

10. Governing Law. The enforcement and interpretation of this Agreement and the transactions
contemplated herein shall be governed by the laws of the United States, including the Electronic Signatures
in Global and National Commerce Act, and, to the extent state law applies, the substantive law of Ohio.
 Page 4

11. Arbitration Provision. This arbitration provision is made pursuant to a transaction involving interstate
commerce and shall be governed by the Federal Arbitration Act. You agree that any and all disputes which
in any way arise out of or relate to this Agreement, shall be resolved solely by binding arbitration before the
American Arbitration Association ("AAA") before a single arbitrator in arbitration commenced as close as
possible to where you reside. Any and all disputes must be brought in the parties’ individual capacity, and
not as a plaintiff or class member in any purported class or representative proceeding. Judgment on the
award rendered by the arbitrator may be entered in any court having jurisdiction over the dispute. Each party
to any such arbitration shall bear its own separate costs and expenses of the arbitration and shall share
equally in the charges of the AAA, including the fee of the arbitrator. However, if you are unable to pay any
fee of the AAA or the arbitrator, we agree to pay those fees for you. By agreeing to arbitration, you and we
are waiving our rights to file a lawsuit and proceed in court and to have a jury trial to resolve disputes. The
word "disputes" is given its broadest possible meaning, and includes all claims; disputes or controversies,
including without limitation any claim or attempt to set aside this arbitration provision. You may choose to
opt-out of this arbitration provision but only by following the process set forth below. If you do not wish to
be subject to this arbitration provision, then you must notify us in writing within sixty (60) calendar days of
the date of this Agreement at the following address: Santa Barbara Tax Products Group, LLC, 11085 North
Torrey Pines Road, Suite 210, La Jolla, CA 92037, Attn. Arbitration Opt-Out. Your written notice must
include your name, address, Social Security Number, the date of this Agreement, and a statement that you
wish to opt out of the arbitration provision. If you choose to opt out, then your choice will apply only to this
Agreement.

12. Customer Identity Validation Disclosure: To help Bank, Processor and the government identify and fight
tax refund fraud, as well as fight the funding of terrorism and money laundering activities, Bank and
Processor obtain, verify, and record information that identifies each Refund Processing Service client. What
this means for you: When you apply to use the Refund Processing Service for the purpose of receiving your
federal tax refund, we will ask for your name, address, date of birth, and other information that will allow us
to identify you. We may also ask to see your driver’s license or other identifying documents if we need to
perform additional due diligence on your account.

YOUR AGREEMENT Bank and Processor agree to all of the terms of this Agreement. By selecting the "I
Agree" button in TurboTax: (i) You authorize Bank to receive your 2016 federal tax refund from the IRS and
Processor to make the deductions from your refund described in the Agreement, (ii) You agree to receive all
communications electronically in accordance with the "Communications" section of the Tax Year 2016
TurboTaxfi User Agreement, (iii) You consent to the release of your 2016 federal tax refund deposit
information and application information as described in Section 2 of this Agreement; and (iv) You
acknowledge that you have reviewed, and agree to be bound by, the Agreement’s terms and conditions. If
this is a joint return, selecting "I Agree" indicates that both spouses agree to be bound by the terms and
conditions of the Agreement.
LaQuana E Chappelle 072-72-7356

Rev. 02/2015

Civista Bank Tax Product Privacy Policy

FACTS What does Civista Bank do with your personal information?

Why? Financial Companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you how
we collect, share, and protect your personal information. Please read this notice carefully to
understand what we do.

What? The types of personal information that we collect and share depend on the product or service
you have with us. This can include:

? Social Security number and account balances

? payment history and transaction history
? overdraft history and account transactions

When you are no longer our customer, we continue to share your information as described in
this notice.

How? All Financial Companies need to share customers’ personal information to run their everyday
business. In the section below we list the reasons financial companies can share their
customers’ personal information; the reasons Civista Bank chooses to share
and whether you can limit the sharing.

Reasons we can share your Does Civista Bank Can you limit this sharing?
personal information Share?

For our everyday business purposes

such as to process your transaction,
maintain your account(s), respond to court Yes No
orders and legal investigations, or report to
credit bureaus.

For our marketing purposes ' No We don’t share

to offer our products and services to you.

For joint marketing with other No We don’t share

financial companies.

For our affiliates’ everyday

business purposes ' No We don’t share
information about your transactions
and experiences.

For our affiliates’ everyday

business purposes ' No We don’t share
information about your creditworthiness.

For our affiliates to market to you. No We don’t share

For non affiliates to market to you. No We don’t share

Questions? Toll Free: 800-901-6663 or go to [Link]

LaQuana E Chappelle 072-72-7356 Page 2

Who we are

Who is providing this notice? Civista Bank

What we do

How does Civista Bank To protect your personal information from unauthorized access
protect my and use, we use security measures that comply with federal law.
personal information? These measures include computer safeguards and secured files
and buildings.

How does Civista Bank We collect personal information about you when you apply for a tax
collect my related product. This includes information in your application, such
personal information? as your name, address, social security number, income,
deductions, refund and the like. We also collect information about
your transactions with us., tax preparers and similar providers, such
as payment histories, balances due, and tax information. We may
also collect information concerning your credit history from a
consumer reporting agency.

Why can’t I limit all sharing? Federal law gives you the right to limit only:

? Sharing for affiliates everyday business purposes '

information about your creditworthiness,
? Affiliates from using your information to market to you,
? Sharing for non affiliates to market to you.

State laws and individual companies may give you additional rights
to limit sharing.

Definitions

Affiliates Companies related by common ownership or control. They can be

financial and nonfinancial companies.

? Civista Bank does not share with our affiliates.

Non affiliates Companies not related by common ownership or control. They can
be financial or nonfinancial companies.

? Civista Bank does not share with non

affiliates so they can market to you.

Joint Marketing A formal joint marketing agreement between non affiliated financial
companies that together market financial products or services
to you.

? Civista Bank does not jointly market.

Other Important Information

This Notice is adopted in recognition of our obligations under Title V of Gramm-Leach Bliley Act of 1999.
This Notice applies only to individuals who have applied for a tax-related bank product.

[Link] 01/08/17
 ELECTRONIC POSTMARK - CERTIFICATION OF ELECTRONIC FILING

Taxpayer: LaQuana E Chappelle

Primary SSN: 072-72-7356

Federal Return Submitted: February 06, 2017 05:30 PM PST

Federal Return Acceptance Date:

Your return was electronically transmitted on 02/06/2017

The Intuit Electronic Postmark shows the date and time Intuit received your federal tax return. The Intuit
Electronic Postmark documents the filing date of your income tax return, and the electronic postmark
information should be kept on file with your tax return and other tax-related documentation.

There are two important aspects of the Intuit Electronic Postmark:

1. THE INTUIT ELECTRONIC POSTMARK.

The electronic postmark shows the date and time Intuit received the federal return, and is deemed the
filing date if the date of the electronic postmark is on or before the date prescribed for filing of the
federal individual income tax return.

TIMELY FILING:
For your federal return to be considered filed on time, your return must be postmarked on or before
midnight April 18, 2017. Intuit’s electronic postmark is issued in the Pacific Time (PT) zone. If you are
not filing in the PT zone, you will need to add or subtract hours from the Intuit Electronic Postmark time
to determine your local postmark time. For example, if you are filing in the Eastern Time (ET) zone and
you electronically file your return at 9 AM on April 18, 2017, your Intuit electronic postmark will indicate
April 18, 2017, 6 AM. If your federal tax return is rejected, the IRS still considers it filed on time if the
electronic postmark is on or before April 18, 2017, and a corrected return is submitted and accepted
before April 23, 2017. If your return is submitted after April 23, 2017, a new time stamp is issued to
reflect that your return was submitted after the IRS deadline and, consequently, is no longer considered
to have been filed on time.

If you request an automatic six-month extension, your return must be electronically postmarked by
midnight October 16, 2017 If your federal tax return is rejected, the IRS will still consider it filed on time
if the electronic postmark is on or before October 17, 2017, and the corrected return is submitted and
accepted by October 20, 2017.

2. THE ACCEPTANCE DATE.

Once the IRS accepts the electronically filed return, the acceptance date will be provided by the Intuit
Electronic Filing Center. This date is proof that the IRS accepted the electronically filed return.
We need your consent - Early Access
This is an IRS requirement

IRS regulations require the following statements:

"Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use
your tax return information for purposes other than the preparation and filing of your tax return without
your consent.

You are not required to complete this form to engage our tax return preparation services. If we obtain
your signature on this form by conditioning our tax return preparation services on your consent, your
consent will not be valid. Your consent is valid for the amount of time that you specify. If you do not
specify the duration of your consent, your consent is valid for one year from the date of signature."

If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@[Link].

To agree, enter your name and date in the boxes below and select the "I Agree" button on the
bottom of the page.

First Name Last Name

Please type the date below:

Date
F7216U01 SBIA5001
Read and accept this Disclosure Consent
This is an IRS requirement

IRS regulations require the following statements:

"Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
disclose your tax return information to third parties for purposes other than the preparation and filing of
your tax return without your consent. If you consent to the disclosure of your tax return information,
Federal law may not protect your tax return information from further use or distribution.

You are not required to complete this form to engage our tax return preparation services. If we obtain
your signature on this form by conditioning our tax return preparation services on your consent, your
consent will not be valid. If you agree to the disclosure of your tax return information, your consent is
valid for the amount of time that you specify. If you do not specify the duration of your consent, your
consent is valid for one year from the date of signature."

If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@[Link].

To agree, enter your name and date in the boxes below and select the "I Agree" button on the
bottom of the page.

Sign this agreement by entering your name:

Please type the date below:

Date

sbia5101 F7216D
Read and accept this Disclosure Consent
This is an IRS requirement

To, enable the Tax Identity restoration protection service that you purchased as part of the MAX
bundle, we need your consent to send some of your personal information to our partner, ID Notify.

Entering your name and date below allows us to disclose the data below to ID Notify's parent
company, CSIdentity Corporation. With your consent, we will send the following:
First Name, Middle Initial, Last Name, Date of Birth, Phone Number, Street Address, City, State,
Zip, Social Security Number, Email Address, Username, and a randomly generated Subscriber Number.

IRS regulations require the following statements:

"Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
disclose your tax return information to third parties for purposes other than the preparation and filing of
your tax return without your consent. If you consent to the disclosure of your tax return information,
Federal law may not protect your tax return information from further use or distribution.

You are not required to complete this form to engage our tax return preparation services. If we obtain
your signature on this form by conditioning our tax return preparation services on your consent, your
consent will not be valid. If you agree to the disclosure of your tax return information, your consent is
valid for the amount of time that you specify. If you do not specify the duration of your consent, your
consent is valid for one year from the date of signature."

If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector General for
Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@[Link].

To agree, enter your name and date in the boxes below and select the "I Agree" button on the
bottom of the page.

I authorize Intuit to send my information listed above to CSIdentity Corporation.

Sign this agreement by entering your name:

Please type the date below:

Date

sbia5102 F7216D02
IMPORTANT DISCLOSURES

If you are owed a federal tax refund, you have a right to choose how you will receive the
refund. There are several options available to you. Please read about these options below.

You can file your tax return electronically or by paper and obtain your refund directly from
the Internal Revenue Service ("IRS") for free. If you file your tax return electronically, you can receive a
refund check directly from the IRS through the U.S. Postal Service in 21 to 28 days from the time you file
your tax return or the IRS can deposit your refund directly into your bank account in less than 21 days
from the time you file your tax return unless there are delays by the IRS. If you file a paper return through
the U.S. Postal Service, you can receive a refund check directly from the IRS through the U.S. Postal
Service in 6 to 8 weeks from the time the IRS receives your return or the IRS can deposit your refund
directly into your bank account in 6 to 8 weeks from the time the IRS receives your return. However, if
your return contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your
refund no earlier than February 15, 2017.

You can file your tax return electronically, select the Refund Processing Service ("RPS"), and have
your federal income tax refund processed through a processor using banking services of a financial
institution. The RPS allows your refund to be deposited into a bank account intended for one-time use
at Civista Bank ("Bank") and deducts your TurboTax fees and other fees you authorize from
your refund. The balance is delivered to you via the disbursement method you select. If you file your tax
return electronically and select the RPS, the IRS will deposit your refund with Bank. Upon Bank's
receipt of your refund, Santa Barbara Tax Products Group, LLC, a processor, will deduct and pay from
your refund any fees charged by TurboTax for the preparation and filing of your tax return and any other
amounts authorized by you and disburse the balance of your refund proceeds to you. Unless there are
delays by the IRS, refunds are received in less than 21 days from the time you file your tax return
electronically. However, if your return contains Earned Income Tax Credit orAdditional Child Tax Credit,
the IRS will issue your refund no earlier than February 15, 2017.

The RPS is not necessary to obtain your refund. If you have an existing bank account,
you do not need to use the RPS in order to receive a direct deposit from the IRS. You
may consult the IRS website ([Link]) for information about tax refund processing.

If you select the RPS, no prior debt you may owe to Bank will be deducted from your
refund.

You can change your income tax withholdings which might result in you receiving additional funds
throughout the year rather than waiting to receive these funds potentially in an income tax refund next
year. Please consult your employer or tax advisor for additional details.

Information regarding low-cost deposit accounts may be available at [Link] .

The chart below shows the options for filing your tax return (e-file or paper return), the
RPS product, refund disbursement options, estimated timing for obtaining your tax refund
proceeds, and costs associated with the various options.
 WHAT TYPE WHAT ARE YOUR WHAT IS THE WHAT COSTS DO YOU
OF FILING DISBURSEMENT ESTIMATED TIME TO INCUR IN ADDITION
METHOD? OPTIONS? RECEIVE REFUND? TO TAX PREPARATION
FEES?

PAPER RETURN IRS direct deposit to Approximately Free

your personal bank 6 to 8 weeks 3
No Refund Processing account.
Service
Check mailed by IRS Approximately
to address on tax 6 to 8 weeks 3
return.

ELECTRONIC IRS direct deposit to Usually within 21 days Free

FILING your personal bank
(E-FILE) account.

No Refund Processing Check mailed by IRS Approximately

Service to address on tax 21 to 28 days 3
return.

ELECTRONIC (a) Direct deposit to Usually within Free option with your
FILING your personal bank 21 days 3 purchase of TurboTax
(E-FILE) account, or Premium Services or
TurboTax MAX 2
Refund Processing (b) Load to your
Service prepaid card 1.

1 You may incur additional charges from the issuer of the prepaid card if you select to have your tax
refund loaded on a prepaid debit card. Bank is not affiliated with the issuer of the prepaid card.

2The cost of TurboTax Premium Services and TurboTax MAX ranges depending on the edition of
TurboTax purchased. See Section 3 of the Refund Processing Agreement on the next page for the cost
of the service you have chosen.

3 However, if your return contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will
issue your refund no earlier than February 15, 2017.

Questions? Call 1-877-908-7228

LaQuana E Chappelle 072-72-7356 1

Smart Worksheets from your 2016 Federal Tax Return

SMART WORKSHEET FOR: Form 1040A: Individual Tax Return

Tax Smart Worksheet

A Tax 0.
Check if from:
1 Tax table X
2 Qualified Dividends and Capital Gain Tax Worksheet
3 Form 8615
B Recapture tax from Form 8863
C Tax. Add lines A and B. Enter the result here and on line 28 0.
LaQuana E Chappelle 072-72-7356 2

SMART WORKSHEET FOR: Dependent Information Worksheet (Alexandria)

Dependency Exemption/EIC Smart Worksheet

NOTE: It is recommended that you answer the questions below using the Step-by-Step mode.
That will help insure that answers to the questions are not inconsistent.

A How many months did this person live with you?

Note: if born or died in current year and lived with you entire
time or qualified missing child select "The whole year". If
more than one-half the year select 7 or more The whole year
B Who are the parents of this person?
To determine if additional questions are necessary for
children of divorced parents.
Both Taxpayer and spouse
Taxpayer X
Spouse
C Did this person provide more than 1/2 their own support? Yes X No
D Was this person married on December 31, 2016 and
filing a joint return for the year (You may answer no if the
only reason the joint return is filed is to get a refund of tax
withheld or estimated tax payments and neither spouse
would have a tax liability on their return if they filed
separate returns)? Yes No
E Is this person a Full time student? Yes No
F Is this person’s gross income less than $4,050? Yes No
1 Did you provide over 1/2 the support for this person?
or
Did you provide over 10% of the support for the person
and with other individuals who would be able to claim
the person except for the support test over 1/2 the
support and all of you have agreed that you alone will
claim the person and you have filled out the Multiple
Support Declaration, Form 2120, to attach to your return? Yes No
G Is there an agreement with this person’s other parent
about who can claim this person as a dependent? X Yes No
Note: The noncustodial parent claiming the exemption for
the child must attach to their return Form 8332 from the
custodial parent releasing the claim to the exemption
for the child
H Who will be claiming this person as a dependent as a result
of
an agreement between the parents
or
as a result of the rules controlling who can claim a qualifying
child when the child meets the conditions to be a
qualifying child of more than one person?
Taxpayer (includes spouse if married filing
joint) in this return? X
Other parent in different return?
Someone else in different return?
LaQuana E Chappelle 072-72-7356 3

SMART WORKSHEET FOR: Dependent Information Worksheet (laquan)

Dependency Exemption/EIC Smart Worksheet

NOTE: It is recommended that you answer the questions below using the Step-by-Step mode.
That will help insure that answers to the questions are not inconsistent.

A How many months did this person live with you?

Note: if born or died in current year and lived with you entire
time or qualified missing child select "The whole year". If
more than one-half the year select 7 or more The whole year
B Who are the parents of this person?
To determine if additional questions are necessary for
children of divorced parents.
Both Taxpayer and spouse
Taxpayer X
Spouse
C Did this person provide more than 1/2 their own support? Yes X No
D Was this person married on December 31, 2016 and
filing a joint return for the year (You may answer no if the
only reason the joint return is filed is to get a refund of tax
withheld or estimated tax payments and neither spouse
would have a tax liability on their return if they filed
separate returns)? Yes No
E Is this person a Full time student? Yes No
F Is this person’s gross income less than $4,050? Yes No
1 Did you provide over 1/2 the support for this person?
or
Did you provide over 10% of the support for the person
and with other individuals who would be able to claim
the person except for the support test over 1/2 the
support and all of you have agreed that you alone will
claim the person and you have filled out the Multiple
Support Declaration, Form 2120, to attach to your return? Yes No
G Is there an agreement with this person’s other parent
about who can claim this person as a dependent? X Yes No
Note: The noncustodial parent claiming the exemption for
the child must attach to their return Form 8332 from the
custodial parent releasing the claim to the exemption
for the child
H Who will be claiming this person as a dependent as a result
of
an agreement between the parents
or
as a result of the rules controlling who can claim a qualifying
child when the child meets the conditions to be a
qualifying child of more than one person?
Taxpayer (includes spouse if married filing
joint) in this return? X
Other parent in different return?
Someone else in different return?
LaQuana E Chappelle 072-72-7356 4

SMART WORKSHEET FOR: Earned Income Credit Worksheet

Nontaxable Combat Pay Election Smart Worksheet

QuickZoom to enter nontaxable combat pay on Form W-2

A Taxpayer:
1 Taxpayer, nontaxable combat pay
2 Election for earned income credit (EIC):
Elect taxpayer’s nontaxable combat pay as earned income for EIC? Yes No
3 Election for dependent care benefits (DCB):
Elect taxpayer’s nontaxable combat pay as earned income for DCB? Yes No
4 Election for child and dependent care credit:
Elect taxpayer’s nontaxable combat pay as earned income
for child and dependent care credit? Yes No

B Spouse:
1 Spouse, nontaxable combat pay
2 Election for earned income credit (EIC):
Elect spouse’s nontaxable combat pay as earned income for EIC? Yes No
3 Election for dependent care benefits (DCB):
Elect spouse’s nontaxable combat pay as earned income for DCB? Yes No
4 Election for child and dependent care credit:
Elect spouse’s nontaxable combat pay as earned income
for child and dependent care credit? Yes No

C You may compare the tax benefit of electing or not electing by checking a box on line A or
line B and reviewing the overpayment or amount due below:

Overpayment 7,171. Amount due

SMART WORKSHEET FOR: Earned Income Credit Worksheet

Investment Income Smart Worksheet

A Taxable and tax exempt interest

B Dividend income
C Capital gain net income
D Royalty and rental of personal property net income
E Passive activity net income:
1 Rental real estate net income or loss
2 Farm rental net income or loss
3 Partnerships and S corporations net income or loss
4 Estates and trusts net income or loss
5 Total of lines 1 through 4
6 Total passive activity net income, line 5 if greater than zero
F Interest and dividends from Forms 8814
G Adjustments
H Total investment income, add lines A through G 0.

Is line H, total investment income over $3,400?

X No. You may take the credit.
Yes. Stop. You cannot take the credit.
LaQuana E Chappelle 072-72-7356 5

SMART WORKSHEET FOR: Earned Income Credit Worksheet

Qualifying Children Smart Worksheet

Year of birth

Was the child under

age 24 at the end of Was the child Lived
2016, a student, and permanently and with
Social security younger than you totally disabled taxpayer
First name MI number (or your spouse, if during any part of in the
Last name Suff Relationship filing jointly)? 2016? U.S.

Alexandria 076-96-5664 2006

Chappelle Daughter Yes No Yes No 12
laquan E 087-98-1840 2009
cameron Son 12
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IT-201
Department of Taxation and Finance

Resident Income Tax Return

New York State • New York City • Yonkers • MCTMT
For the full year January 1, 2016, through December 31, 2016, or fiscal year beginning .... 16
and ending ....
For help completing your return, see the instructions, Form IT-201-I.
Your first name MI Your last name (for a joint return, enter spouse’s name on line below) Your date of birth (mmddyyyy) Your social security number

LAQUANA E CHAPPELLE 04141987 072727356

Spouse’s first name MI Spouse’s last name Spouse’s date of birth (mmddyyyy) Spouse’s social security number

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

Mailing address (see instructions, page 13) (number and street or PO box) Apartment number New York State county of residence

329 BRISTOL ST E KINGS

City, village, or post office State ZIP code Country (if not United States) School district name
BROOKLYN NY 11212 BROOKLYN
Taxpayer’s permanent home address (see instructions, page 13) (number and street or rural route) Apartment number
School district
code number ................ 071
City, village, or post office State ZIP code Taxpayer’s date of death (mmddyyyy) Spouse’s date of death (mmddyyyy)
Decedent
NY information

A Filing  Single D1 Did you have a financial account

located in a foreign country? (see page 14) ........... Yes No
status
(mark an Married filing joint return D2Yonkers residents and Yonkers part-year residents only:
 (enter spouse’s social security number above)
X in one (1) Did you receive a property tax freeze or
box): Married filing separate return property tax relief credit?
 (enter spouse’s social security number above) (see page 14) ..................................................  Yes No
(2) If Yes, enter the
 Head of household (with qualifying person) total amount ............ .00

 Qualifying widow(er) with dependent child E(1) Did you or your spouse maintain living
quarters in NYC during 2016? (see page 14) ... Yes No

B Did you itemize your deductions on (2) Enter the number of days spent in NYC in 2016
your 2016 federal income tax return? ............. Yes No (any part of a day spent in NYC is considered a day)..........

C Can you be claimed as a dependent F NYC residents and NYC part-year

on another taxpayer’s federal return? ............ Yes No residents only (see page 14):
(1) Number of months you lived in NYC in 2016 ................. 12
(2) Number of months your spouse
lived in NYC in 2016 ........................................................

G Enter your 2‑character special condition

code(s) if applicable (see page 14) .......................

H Dependent exemption information (see page 15)

First name MI Last name Relationship Social security number Date of birth (mmddyyyy)

ALEXANDRIA CHAPPELLE DAUGHTER 076965664 09212006

LAQUAN E CAMERON SON 087981840 01252009

If more than 7 dependents, mark an X in the box.

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Page 2 of 4 IT-201 (2016) Your social security number
072727356
Federal income and adjustments (see page 15)
Whole dollars only

1 Wages, salaries, tips, etc. ............................................................................................................ 1 11754 .00

2 Taxable interest income ............................................................................................................... 2 .00
3 Ordinary dividends ....................................................................................................................... 3 .00
4 Taxable refunds, credits, or offsets of state and local income taxes (also enter on line 25) ............ 4 .00
.00

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

5 Alimony received .......................................................................................................................... 5
6 Business income or loss (submit a copy of federal Schedule C or C-EZ, Form 1040) ........................... 6 .00
7 Capital gain or loss (if required, submit a copy of federal Schedule D, Form 1040) ............................... 7 .00
8 Other gains or losses (submit a copy of federal Form 4797) .............................................................. 8 .00
9 Taxable amount of IRA distributions. If received as a beneficiary, mark an X in the box .... 9 .00
10 Taxable amount of pensions and annuities. If received as a beneficiary, mark an X in the box. 10 .00
11 Rental real estate, royalties, partnerships, S corporations, trusts, etc. (submit copy of federal Schedule E, Form 1040) 11 .00

12 Rental real estate included in line 11 .................................. 12 .00

13 Farm income or loss (submit a copy of federal Schedule F, Form 1040) .............................................. 13 .00
14 Unemployment compensation ...................................................................................................... 14 .00
15 Taxable amount of social security benefits (also enter on line 27) ................................................... 15 .00
16 Other income (see page 15) Identify: 16 .00
17 Add lines 1 through 11 and 13 through 16 ................................................................................ 17 11754 .00
18 Total federal adjustments to income (see page 15) Identify: 18 .00
19 Federal adjusted gross income (subtract line 18 from line 17) ...................................................... 19 11754 .00

New York additions (see page 16)

20 Interest income on state and local bonds and obligations (but not those of NYS or its local governments). 20 .00
21 Public employee 414(h) retirement contributions from your wage and tax statements (see page 16). 21 .00
22 New York’s 529 college savings program distributions (see page 16)........................................... 22 .00
23 Other (Form IT-225, line 9) .............................................................................................................. 23 .00
24 Add lines 19 through 23 ............................................................................................................... 24 11754 .00

New York subtractions (see page 17)

25 Taxable refunds, credits, or offsets of state and local income taxes (from line 4). 25 .00
26 Pensions of NYS and local governments and the federal government (see page 17) . 26 .00
27 Taxable amount of social security benefits (from line 15) ......... 27 .00
28 Interest income on U.S. government bonds ....................... 28 .00
29 Pension and annuity income exclusion (see page 18) ......... 29 .00
30 New York’s 529 college savings program deduction/earnings. 30 .00
31 Other (Form IT-225, line 18).................................................... 31 .00
32 Add lines 25 through 31 ............................................................................................................... 32 .00
33 New York adjusted gross income (subtract line 32 from line 24) ................................................... 33 11754 .00

Standard deduction or itemized deduction (see page 20)

34 Enter your standard deduction (table on page 20) or your itemized deduction (from Form IT-201-D)
Mark an X in the appropriate box: Standard  - or - Itemized 34 11150 .00
35 Subtract line 34 from line 33 (if line 34 is more than line 33, leave blank) ........................................... 35 604 .00
36 Dependent exemptions (enter the number of dependents listed in item H; see page 20) ...................... 36 2 000.00
37 Taxable income (subtract line 36 from line 35) ................................................................................ 37 .00

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Name(s) as shown on page 1 Your social security number IT-201 (2016) Page 3 of 4
LAQUANA E CHAPPELLE 072727356

Tax computation, credits, and other taxes

38 Taxable income (from line 37 on page 2) ........................................................................................ 38 .00

39 NYS tax on line 38 amount (see page 21) ...................................................................................... 39 0 .00
40 NYS household credit (page 21, table 1, 2, or 3) .................... 40 90 .00
.00

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

41 Resident credit (see page 22) ................................................ 41
42 Other NYS nonrefundable credits (Form IT-201-ATT, line 7) . 42 .00
43 Add lines 40, 41, and 42 .............................................................................................................. 43 90 .00
44 Subtract line 43 from line 39 (if line 43 is more than line 39, leave blank) ........................................... 44 .00
45 Net other NYS taxes (Form IT-201-ATT, line 30) .............................................................................. 45 .00
46 Total New York State taxes (add lines 44 and 45) ......................................................................... 46 .00
New York City and Yonkers taxes, credits, and surcharges, and MCTMT
47 NYC resident tax on line 38 amount (see page 22).............. 47 0 .00 See instructions on
pages 22 through 25 to
48 NYC household credit (page 22, table 4, 5, or 6)................... 48 90 .00
compute New York City and
49 Subtract line 48 from line 47 (if line 48 is more than Yonkers taxes, credits, and
  line 47, leave blank) ........................................................... 49 .00 surcharges, and MCTMT.
50 Part-year NYC resident tax (Form IT-360.1) ....................... 50 .00
51 Other NYC taxes (Form IT-201-ATT, line 34) ......................... 51 .00
52 Add lines 49, 50, and 51 ................................................... 52 .00
53 NYC nonrefundable credits (Form IT-201-ATT, line 10) ......... 53 .00
54 Subtract line 53 from line 52 (if line 53 is more than
  line 52, leave blank) .......................................................... 54 .00
54a MCTMT net
  earnings base..... 54a .00
54b MCTMT............................................................................. 54b .00
55 Yonkers resident income tax surcharge (see page 25) ...... 55 .00
56 Yonkers nonresident earnings tax (Form Y-203) ................ 56 .00
57 .Part-year Yonkers resident income tax surcharge (Form IT-360.1) 57 .00
58 Total New York City and Yonkers taxes / surcharges and MCTMT (add lines 54 and 54b through 57)... 58 .00

59 Sales or use tax (see page 26; do not leave line 59 blank) ........................................................... 59 0 .00
Voluntary contributions ( see page 27)
60a Return a Gift to Wildlife ................................................................ 60a .00
60b Missing/Exploited Children Fund .................................................. 60b .00
60c Breast Cancer Research Fund ..................................................... 60c .00
60d Alzheimer’s Fund .......................................................................... 60d .00
60e Olympic Fund ($2 or $4; see page 27) ............................................. 60e .00
60f Prostate and Testicular Cancer Research and Education Fund ... 60f .00
60g 9/11 Memorial ............................................................................... 60g .00
60h Volunteer Firefighting & EMS Recruitment Fund .......................... 60h .00
60i Teen Health Education.................................................................. 60i .00
60j Veterans Remembrance................................................................ 60j .00
60k Homeless Veterans....................................................................... 60k .00
60l Mental Illness Anti-Stigma Fund ................................................... 60l .00
60m Women’s Cancers Education and Prevention Fund ..................... 60m .00
60n Autism Fund ................................................................................. 60n .00
60 Total voluntary contributions (add lines 60a through 60n) ............................................................ 60 .00
61 Total New York State, New York City, Yonkers, and sales or use taxes, MCTMT, and
  voluntary contributions (add lines 46, 58, 59, and 60) ............................................................... 61 .00

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072727356
62 Enter amount from line 61 ............................................................................................................ 62 .00

Payments and refundable credits (see page 28)

63 Empire State child credit .................................................... 63 434 .00
63a Family tax relief credit ........................................................ 63a .00
64 NYS/NYC child and dependent care credit ........................ 64 208 .00
65 NYS earned income credit (EIC) ................................. 65 1413 .00
66 NYS noncustodial parent EIC ............................................ 66 .00

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

67 Real property tax credit ...................................................... 67 .00
68 College tuition credit ........................................................... 68 .00
69 NYC school tax credit (also complete F on page 1; see page 29) 69 63 .00
70 NYC earned income credit ............................................ 70 236 .00
70a NYC enhanced real property tax credit ............................... 70a .00
71 Other refundable credits (Form IT-201-ATT, line 18) ............... 71 .00 If applicable, complete Form(s) IT-2
72 Total New York State tax withheld ..................................... 72 416 .00 and/or IT-1099-R and submit them
with your return (see page 12).
73 Total New York City tax withheld ....................................... 73 300 .00
74 Total Yonkers tax withheld ................................................. 74 .00 Do not send federal Form W-2
with your return.
75 Total estimated tax payments and amount paid with Form IT-370. 75 .00
76 Total payments (add lines 63 through 75) ....................................................................................... 76 3070 .00
Your refund, amount you owe, and account information (see pages 31 through 33)
77 Amount overpaid (if line 76 is more than line 62, subtract line 62 from line 76) .................................. 77 3070 .00
78 Amount of line 77 to be refunded direct paper
Mark one refund choice: deposit (fill in line 83) - or - check .............................. 78 3070 .00
79 Amount of line 77 that you want applied to your Refund? Direct deposit is the
  2017 estimated tax (see instructions) ................................ 79 .00 easiest, fastest way to get your
refund.
80 Amount you owe (if line 76 is less than line 62, subtract line 76 from line 62). To pay by electronic See page 32 for payment options.
  funds withdrawal, mark an X in the box and fill in lines 83 and 84. If you pay by check
  or money order you must complete Form IT-201-V and mail it with your return. ..................... 80 .00
81 Estimated tax penalty (include this amount in line 80 or
reduce the overpayment on line 77; see page 31) .................. 81 .00 See page 35 for the proper
assembly of your return.
82 Other penalties and interest (see page 32) .......................... 82 .00
83 Account information for direct deposit or electronic funds withdrawal (see page 32).
If the funds for your payment (or refund) would come from (or go to) an account outside the U.S., mark an X in this box (see pg. 32)

83a Account type: Personal checking - or - Personal savings - or - Business checking - or - Business savings

83b Routing number 026008811 83c Account number 6806591399

84 Electronic funds withdrawal (see page 33) .................... Date Amount .00

Third-party Print designee’s name Designee’s phone number Personal identification

number (PIN)
designee? (see instr.) (    )
Yes No E-mail:

▼ Paid preparer must complete ▼ Preparer’s NYTPRIN NYTPRIN

▼ Taxpayer(s) must sign here ▼
(see instructions) excl. code
Preparer’s signature Preparer’s printed name Your signature

Firm’s name (or yours, if self-employed) Preparer’s PTIN or SSN Your occupation
SELF-PREPARED SOCIAL WORKER
Address Employer identification number Spouse’s signature and occupation (if joint return)

Date Date Daytime phone number

(   
347 ) 693-7600
E-mail: E-mail:

See instructions for where to mail your return.

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 REV 01/25/17 [Link]
Department of Taxation and Finance

Claim for Empire State Child Credit IT-213

Submit this form with Form IT-201 or IT-203.
Step 1 – Enter identifying information
Your name as shown on return Your social security number

LAQUANA E CHAPPELLE 072727356

Spouse’s name Spouse’s social security number

Step 2 – Determine eligibility

1 Were you (and your spouse if filing a joint New York State return) New York State residents for all of 2016? 1 Yes No
If you marked an X in the No box, stop; you do not qualify for this credit.

NO HANDWRITTEN ENTRIES ON THIS FORM

2 Did you claim the federal child tax credit or additional child tax credit for 2016?........................................ 2 Yes No

3 Is your federal adjusted gross income (see instructions)

– $110,000 or less and your filing status is  married filing joint return;
– $75,000 or less and your filing status is  single,  head of household, or  qualifying widow(er); or
– $55,000 or less and your filing status is  married filing separate return?........................................... 3 Yes No
If you marked an X in the No box at both lines 2 and 3, stop; you do not qualify for this credit.

4 Enter the number of children who qualify for the federal child tax credit or
  additional child tax credit (see instructions)................................................................................................ 4 2

5 Enter the number of children from line 4 that were at least four but less than 17 years of age on December 31, 2016... 5 2
If you entered 0 on line 5, stop; you do not qualify for this credit.

Step 3 – Enter child information

List below the name, social security number, and date of birth for each child included on line 4.
Social security Date of birth
First name MI Last name Suffix number (mmddyyyy)

ALEXANDRIA CHAPPELLE 076965664 09212006

LAQUAN E CAMERON 087981840 01252009

Use Form IT-213-ATT if you have additional children to report (see instructions).

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IT-213 (2016) (back)

Step 4 – Compute credit

If you answered No to question 2, skip lines 6 through 12, and enter 0 on line 13; continue with line 14.
Whole dollars only

6 Enter your federal child tax credit from Form 1040A, line 35, or Form 1040, line 52 ............................. 6 .00

7 Enter your federal additional child tax credit from Form 1040A, line 43, or Form 1040, line 67.............. 7 1313 .00

8 Add lines 6 and 7..................................................................................................................................... 8 1313 .00

9 Enter the number of children from line 4................................................................................................. 9 2

10 Divide line 8 by line 9 ............................................................................................................................. 10 657 .00

11 Enter the number of children from line 5................................................................................................. 11 2

12 Multiply line 10 by line 11......................................................................................................................... 12 1314 .00

NO HANDWRITTEN ENTRIES ON THIS FORM

13 Multiply line 12 by 33% (.33)................................................................................................................... 13 434 .00

If you marked the No box on line 3, skip lines 14 and 15, and enter the amount from line 13 on line 16.
All others continue with line 14.

14 Enter the number of children from line 5................................................................................................. 14 2

15 Multiply line 14 by 100............................................................................................................................. 15 200 .00

16 Empire State child credit (enter the amount from line 13 or line 15, whichever is greater)................................ 16 434 .00

If you filed a joint federal return but are required to file separate New York State returns, continue with
lines 17 and 18. All others enter the line 16 amount on Form IT-201, line 63.

Step 5 – Spouses required to file separate New York State returns (see instructions)

17 Enter the full-year resident spouse’s share of the line 16 amount; do not leave line 17 blank ............ 17 .00
  Enter here and on Form IT-201, line 63.

18 Enter the part-year resident or nonresident spouse’s share of the line 16 amount;
  do not leave line 18 blank ................................................................................................................ 18 .00
  Enter the line 18 amount and code 213 on Form IT-203-ATT, line 12.

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IT-215
Department of Taxation and Finance

Claim for Earned Income Credit

New York State • New York City

Submit this form with Form IT-201 or IT-203.

Name(s) as shown on return Your social security number
LAQUANA E CHAPPELLE 072727356

1 Did you claim the federal earned income credit? If No, stop; you do not qualify for these credits. ........................ 1 Yes No
2 Is your investment income (see instructions) greater than $3,400? If Yes, stop; you do not qualify for these credits. ....... 2 Yes No
3 Have you already filed your New York State income tax return? If Yes, you must file an amended NYS return.......... 3 Yes No
4 Did you claim qualifying children on your federal Schedule EIC? If No, continue with line 5.
 If Yes, in the spaces below, list up to three of the same children you claimed on federal Schedule EIC. ................. 4 Yes No
  If you claimed more than three, see instructions.
No. of Full Person
months time with Social security Date of birth
First name MI Last name Suffix lived student disability* number (mmddyyyy)
with you *

NO HANDWRITTEN ENTRIES ON THIS FORM

ALEXANDRIA CHAPPELLE 12 076965664 09212006
LAQUAN E CAMERON 12 087981840 01252009

* Mark an X in these boxes only if you checked Yes in the same box on your federal Schedule EIC (box 4a or 4b).
5 Is the IRS figuring your federal earned income credit (EIC) for you? If Yes, complete lines 6 through 9 (also lines 21,
  23, and 24 if you are a part-year New York State resident, and line 28 if you are a part‑year New York City resident).
  The Tax Department will compute your New York State and, if applicable, your New York City earned income
  credit for you. If No, complete lines 6 through 17 (and lines 18 through 26 if you are a part-year New York State
  resident). New York City residents must complete the New York City earned income credit Worksheet C on
  page 3 of Form IT‑215‑I. Part‑year New York City residents must also complete line 28 on the back of this claim form. ...... 5 Yes No
Whole dollars only

6 Wages, salaries, tips, etc., from Worksheet A line 3, on page 2 of the instructions, Form IT-215-I. ............................. 6 11754 .00
7 Earned income adjustments (see instructions) .................................................................................................................. 7 .00
8 Business income or loss (from your federal Form 1040 line instructions, Earned Income Credit Worksheet B, lines 1e, 2c, and 3) .... 8 .00
Employer identification number (see instructions)....
9 Enter your federal adjusted gross income
 (from Form IT-201, line 19, or Form IT-203, line 19, Federal amount column) .......................................................................... 9 11754 .00
10 Amount of federal EIC claimed (from federal Form 1040EZ, line 8a; Form 1040A, line 42a; or Form 1040, line 66a) ............... 10 4710 .00
11 New York State earned income credit (NYS EIC) rate 30% (.30) .................................................................................. 11 .30
12 Tentative NYS EIC (multiply line 10 by line 11; see instructions) ............................................................................................ 12 1413 .00
Complete Worksheet B on the back page before continuing.
13Enter the amount from Worksheet B, line 5, on the back of this form.................... 13 .00
14 New York State household credit (from Form IT-201, line 40, or Form IT-203, line 39)... 14 90 .00
15 Enter the smaller of line 13 or line 14 ............................................................................................................................ 15 .00
16 Allowable New York State earned income credit (subtract line 15 from line 12; see instructions) ..................................... 16 1413 .00
17 If your New York State filing status is , Married filing separate return, complete line 17. The NYS EIC on
  line 16 above can be divided between spouses in any manner you wish. Enter on line 17 the amount
  of NYS EIC from line 16 you are claiming, and also enter your joint federal adjusted gross income below. ................. 17 .00
   Federal adjusted gross income (from federal Form 1040EZ, line 4;
Form 1040A, line 22; or Form 1040, line 38) ..................................................................... .00

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IT-215 (2016) (back)

Part-year New York State resident earned income credit

Lines 18 through 26 apply only to part-year New York State

residents claiming the New York State earned income credit.
18 Enter your New York State earned income credit (from line 16 or line 17) ......................................................................... 18 .00
19 Enter the amount from Form IT-203, line 42 .................................................................................................................. 19 .00
– If line 19 is equal to or more than line 18, stop. You do not have excess New York State earned income credit.
– If line 19 is less than line 18, continue on line 20 below.
20 Excess New York State earned income credit (subtract line 19 from line 18) ................................................................. 20 .00
21 Enter the amount from Form IT-203-ATT, line 31 (If you do not have to file Form IT-203-ATT, leave blank and continue on line 22 below.) 21 .00
– If Form IT-215, line 21, is equal to or more than Form IT-215, line 20, stop. Do not continue
  with this computation. Enter the amount from line 20 above on Form IT-203-ATT, line 32.
– If Form IT-215, line 21, is less than Form IT‑215, line 20, enter the amount from line 20 above on
  Form IT-203-ATT, line 32, and continue on line 22 below.
22 Subtract line 21 from line 20. This is your remaining excess New York State earned income credit. .................... 22 .00

NO HANDWRITTEN ENTRIES ON THIS FORM

23 Enter the amount from line 19, Column D, of the Part-year resident
  income allocation worksheet in your Form IT-203 instruction booklet ....................... 23 .00
24 Enter the amount from line 19, Column A, of the Part-year resident
  income allocation worksheet in your Form IT-203 instruction booklet ....................... 24 .00

25 Divide line 23 by line 24 (round the result to the fourth decimal place). This amount cannot exceed 100% (1.0000). .......... 25
26 Multiply line 22 by line 25. Enter the result here and on Form IT-203-ATT, line 10.
 This is the refundable portion of your part-year New York State resident earned income credit. ................... 26 .00

New York City earned income credit (full-year and part-year New York City residents)

27 From Worksheet C, New York City earned income credit, on page 3 of Form IT-215-I, Instructions for
 Form IT-215. Enter here and on Form IT-201, line 70, or Form IT-203-ATT, line 11. ............................................... 27 236 .00
  Part-year New York City residents must also complete line 28 below.
28 Part-year New York City adjusted gross income
  Enter the amounts from Worksheet C, lines 6 and 7 ......................................... 28A .00 28B .00

Worksheet B

1 New York State tax (from Form IT-201, line 39, or Form IT-203, line 38) ................................................................................. 1 .00
2 Resident credit (see instructions) ..................................................................................... 2 .00
3 Accumulation distribution credit (see instructions) ........................................................... 3 .00
4 Add lines 2 and 3 ........................................................................................................................................................... 4 .00
5 Subtract line 4 from line 1. (If line 4 is more than line 1, enter 0.) Enter here and on line 13 on the front of this form. .......... 5 .00

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 REV 01/25/17 [Link]

IT-216
Department of Taxation and Finance

Claim for Child and Dependent Care Credit

New York State • New York City

Submit this form with Form IT-201 or IT-203.

Name(s) as shown on return Your social security number
LAQUANA E CHAPPELLE 072727356

1 Have you already filed your New York State income tax return?.................................................................................... Yes No
  If Yes, you must file an amended New York State return and include Form IT-216 to claim this credit.

2 Persons or organizations who provided the care. (If you have more than two providers, see instructions.)
A – Care provider name (first name, middle initial, and last name, or business name) C – Identifying number (SSN or EIN) D – Amount paid (see instr.)
1st KHALIL CHAPPELLE 105-86-1152 541 .00
Care B – Number and street City State ZIP code
provider
329 BRISTOL STREET BROOKLYN NY 11212
A – Care provider name (first name, middle initial, and last name, or business name) C – Identifying number (SSN or EIN) D – Amount paid (see instr.)
2nd .00

NO HANDWRITTEN ENTRIES ON THIS FORM

Care B – Number and street City State ZIP code
provider

3 Qualifying persons you are claiming. List in order from youngest to oldest.
  (If you are claiming more than four qualifying persons, mark an X in the box and see instructions.) ................................................

A B C D E F
Person
First Last Qualified with Social security Date of birth
name MI name Suffix expenses paid disability number (mmddyyyy)
(see instr.)

LAQUAN E CAMERON 541 .00 087981840 01252009

.00

.00

.00
Note: If you are claiming expenses paid for a dependent child, include only those qualified expenses paid through the day preceding the child’s
13th birthday.
3a Total of line 3, column C amounts. Include amounts from additional sheet(s), if any ............................. 3a 541 .00

4 Can you claim an exemption for all the qualified persons listed on line 3 and any additional sheet(s)?......................Yes No

5 Enter the smallest of:

– line 3a above; or
Whole dollars only
– federal Form 2441, line 3; or
– 3,000 if one qualifying person, or 6,000 if two or more qualifying persons ....................................... 5 541.00
6 Enter your earned income (see instructions) ............................................................................................. 6 11754.00
7 If your filing status is  Married filing joint return, enter your spouse’s earned income;
all others, enter the amount from line 6 (see instructions) ..................................................................... 7 11754.00
8 Enter the smallest of line 5, 6, or 7.......................................................................................................... 8 541.00
9 Enter the amount from: federal Form 1040A, line 22,
or federal Form 1040, line 38................................................. 9 11754 .00
10 Enter the decimal amount that applies to the amount
on line 9 from the Table for line 10 in the instructions ........................................................................ 10 .35

11 Multiply line 8 by the decimal amount on line 10 (enter here and on line 12 on the back) ............................ 11 189.00

216001161555
REV 01/25/17 [Link]
IT-216 (2016) (back)

12 Amount from line 11................................................................................................................................ 12 189.00

13 Enter your New York adjusted gross income (Form IT-201 filers,
line 33; Form IT-203 filers, line 32) ................................................ 11754 .00
Use the New York State child and dependent care
  credit limitation table in the instructions to determine the decimal to be entered on this line.............. 13 1.100
14 Multiply line 12 by the decimal amount on line 13. This is your New York State child and dependent
  care credit (see instructions) ................................................................................................................... 14 208.00
Part-year New York State residents
15 Enter the amount from Form IT-203, line 40 .......................................................................................... 15 .00
If line 15 is equal to or more than line 14, stop. You do not have excess credit.
If line 15 is less than line 14, continue on line 16 below.
16 Subtract line 15 from line 14. This is your excess child and dependent care credit ........................ 16 .00
17 Enter the amount from Form IT-203-ATT, line 29 (If you are not required to file Form IT-203-ATT, leave
  blank and continue on line 18 below.) ....................................................................................................... 17 .00
If line 17 is equal to or more than line 16, stop. Do not continue with this worksheet. Enter the line 16 amount

NO HANDWRITTEN ENTRIES ON THIS FORM

on Form IT-203-ATT, line 30.
If line 17 is less than line 16, enter the line 16 amount on Form IT-203-ATT, line 30, and continue on line 18 below.
18 Subtract line 17 from line 16. This is your remaining excess child and dependent care credit ..... 18 .00
19 Enter the amount from line 19, Column D, of the
  Part-year resident income allocation worksheet
in the instructions for Form IT-203 ......................................... 19 .00
20 Enter the amount from line 19, Column A, of the
  Part-year resident income allocation worksheet
  in the instructions for Form IT-203.......................................... 20 .00
21 Divide line 19 by line 20 (round the result to the fourth decimal place).
  This amount cannot exceed 100% (1.0000) ......................................................................................... 21
22 Multiply line 18 by line 21. Enter the result here and on Form IT-203-ATT, line 9. This is the
  refundable portion of your New York State part-year resident child and dependent care credit. 22 .00

New York City child and dependent care credit

If you were a resident of New York City at any time during the tax year and your federal adjusted gross income
is $30,000 or less (see Note under New York City credit on page 1 of the instructions) and you listed a child under
4 years old as of December 31, on line 3, complete line 23 and see page 4 of the instructions.
23 Enter the portion of the total expenses from line 3a that was paid for children under 4 years old ......... 23 .00

IT-201 filers:
24 Refundable New York City child and dependent care credit (from Worksheet 1, line 7 or line 13) ............... 24 .00
25 Add lines 14 and 24; also enter this amount on Form IT-201, line 64..................................................... 25 .00

26 Part-year New York City resident nonrefundable New York City child and dependent care credit
  (from Worksheet 1, line 8); also enter this amount on Form IT-201-ATT, line 9a .................................... 26 .00

IT-203 filers:
27 Nonrefundable portion of your part-year New York City resident New York City child and dependent
  care credit (from Worksheet 1, line 8); also enter this amount on Form IT-203, line 52 .......................... 27 .00
28 Refundable portion of your part-year New York City resident New York City child and dependent
  care credit (from Worksheet 1, line 13); also enter this amount on Form IT-203-ATT, line 9a ................. 28 .00
Part-year New York City resident filers only:
29 Enter the amount from Worksheet 1, line 10 .......................................................................................... 29 .00
30 Enter the amount from Worksheet 1, line 11 .......................................................................................... 30 .00

216002161555
 IT-2
REV 01/25/17 [Link]
Department of Taxation and Finance

Summary of W-2 Statements

New York State • New York City • Yonkers
Do not detach or separate the W-2 Records below. File Form IT-2 as an entire page with your return. See instructions on the back.
Box c Employer’s information
W-2 Record 1 Employer’s name

Box a Employee’s social security number SCO FAMILY OF SERVICES

for this W-2 Record Employer’s address (number and street)
072727356 ONE ALEXANDER PLACE
Box b Employer identification number (EIN) City State ZIP code Country (if not United States)

112777066 GLEN COVE NY 11542

Box 1 Wages, tips, other compensation Box 12a Amount Code Box 14a Amount Description
8526 .00 .00 8 .00 NYSDI
Box 8 Allocated tips Box 12b Amount Code Box 14b Amount Description
.00 .00 .00
Box 10 Dependent care benefits Box 12c Amount Code Box 14c Amount Description
.00 .00 .00
Box 11 Nonqualified plans Box 12d Amount Code Box 14d Amount Description

NO HANDWRITTEN ENTRIES ON THIS FORM

.00 .00 .00

Box 13 Statutory employee Retirement plan Third-party sick pay Corrected (W-2c)
Box 16a NYS wages, tips, etc. Box 17a NYS income tax withheld
NY State information: Box 15a
NY State N Y 8526 .00 333 .00
Box 16b Other state wages, tips, etc. Box 17b Other state income tax withheld
Other state information: Box 15b
other state .00 .00

NYC and Yonkers Box 18 Local wages, tips, etc. Box 19 Local income tax withheld Box 20 Locality name
information (see instr.):
Locality a 8526 .00 Locality a 217 .00 Locality a NYC

Locality b .00 Locality b .00 Locality b

Do not detach. Box c Employer’s information

W-2 Record 2 Employer’s name

Box a Employee’s social security number UNITED STATES POSTAL SERVICE EAG AN ACCOUNTING SERVICE CENTER
for this W-2 Record Employer’s address (number and street)
072727356 2825 LONE OAK PARKWAY
Box b Employer identification number (EIN) City State ZIP code Country (if not United States)

410760000 EAGAN MN 55121-9617

Box 1 Wages, tips, other compensation Box 12a Amount Code Box 14a Amount Description
3228.00 .00 .00
Box 8 Allocated tips Box 12b Amount Code Box 14b Amount Description
.00 .00 .00
Box 10 Dependent care benefits Box 12c Amount Code Box 14c Amount Description
.00 .00 .00
Box 11 Nonqualified plans Box 12d Amount Code Box 14d Amount Description
.00 .00 .00

Box 13 Statutory employee Retirement plan Third-party sick pay Corrected (W-2c)
Box 16a NYS wages, tips, etc. Box 17a NYS income tax withheld
NY State information: Box 15a
NY State N Y 3228 .00 83 .00
Box 16b Other state wages, tips, etc. Box 17b Other state income tax withheld
Other state information: Box 15b
other state .00 .00

NYC and Yonkers Box 18 Local wages, tips, etc. Box 19 Local income tax withheld Box 20 Locality name
information (see instr.):
Locality a 3228 .00 Locality a 83 .00 Locality a NYC

Locality b .00 Locality b .00 Locality b

102001161555
 New York State Information Worksheet 2016
G Keep for your records

Part I ' Personal Information

Taxpayer: Spouse:
First Name LAQUANA First Name
Middle Initial E Suffix Middle Initial Suffix
Last Name CHAPPELLE Last Name
Social Security No. 072-72-7356 Social Security No.
Occupation social worker Occupation
Date of Birth 04-14-1987 Date of Birth
Age as of 1-1-2017 29 Age as of 1-1-2017
Date of Death Date of Death
NY DL Doc ID 0060508652 NY DL Doc ID
Email Address Email Address
Daytime Phone (347)693-7600 Daytime Phone
Extension Extension
Home Phone

Check to print phone number on main form Home X Taxpayer daytime Spouse daytime

Mailing Address
Street Address 329 BRISTOL ST Apartment No. E
City brooklyn State NY ZIP Code 11212
Foreign code Foreign country Foreign postal code
Foreign province/county Foreign province/county abbreviation

Permanent Home Address (if different from mailing address above)

Street Address Apartment No.
City State ZIP Code
(Below should be used by New York nonresidents only)
Foreign code Foreign country Foreign postal code
Foreign province/county Foreign province/county abbreviation
New York County and School District Information
County Kings
School District Brooklyn School District Code 071
Part II ' Main Form

X Full-year resident: Form IT-201, Resident Income Tax Return

Part-year resident: Form IT-203, Nonresident and Part-Year Resident Income Tax
Return
Nonresident: Form IT-203, Nonresident and Part-Year Resident Income Tax Return

Taxpayer Spouse
If only one spouse has New York source income, check the box related to that spouse

New York City and City of Yonkers Residency Information:

Taxpayer Spouse

New York City Yonkers New York City Yonkers

Residency Status:
Full-year resident X
Part-year resident
Nonresident X

Part-year residents dates of residency:

From:
To:

If a City of Yonkers nonresident:

Did you receive income or withholding
from Yonkers sources during your Yes Yes
period of nonresidence? No X No

New York City Residents:

Yes No
X Did you or your spouse maintain living quarters in New York City during 2016?

X If married, did you or your spouse change New York City resident status at different times
during the year? A ’Yes’ response will generate separate Forms 360.1 for taxpayer and spouse.
LAQUANA E CHAPPELLE 072-72-7356 Page 2

Part III ' Filing Status

Single
Married, filing joint
Married, filing separate
You did not live with your spouse at any time during the year
If both you and your spouse itemized deductions on your federal tax return:
Both you and your spouse will itemize deductions on your New York State tax returns
Both you and your spouse will take the New York standard deduction
X Head of household
Qualifying widow(er)

Part IV ' Credits

New York City Accumulation Distribution Credit:

Taxpayer Spouse

New York State and New York City Household Credit for Married Filing Separate Taxpayers:
Number of exemptions claimed on spouse’s return
Adjusted gross income (IT-201 or IT-203, line 19) from spouse’s return
Total Build America Bond (BAB) interest included on spouse’s federal income tax return

Refundable Credits Paid in Advance:

Yes No
X Did you receive a check(s) from the NY Tax Department for the property tax freeze or
property tax relief credits? (do not include any STAR credit received here)
If Yes, enter the amount

Check received for STAR credit

New York State Public Trust Act (new question at top of forms IT-201-ATT and IT-203-ATT):
Have you (or an entity of which you are an owner) been convicted of Bribery
Involving Public Servants and Related Offenses, Corrupting the Government, or
Defrauding the Government (NYS Penal Law Article 200, 496, or section 195.20)? Yes No
Note: Checking "Yes" above makes you not eligible for any business tax credits
allowed under Tax Law Article 22, Personal Income Tax.

Part V ' New York City Unincorporated Business Tax Return

Taxpayer Spouse

1a File NYC-202S
b File NYC-202
c Do not file NYC-202/NYC-202S
2 Gain (loss) from sale of business assets
3 Net rent/royalty income from business property
4 Other business income (loss)
5 Income taxes/unincorporated business taxes paid and
deducted on federal Schedule C or Schedule C-EZ
6 Number of months in business in New York City during the
year
7a Use direct deposit for NYC-202/NYC-202S tax refund Yes No Yes No
b Will the funds for this refund go to an account outside the
U.S.? Yes No Yes No
c Routing number
d Account number
e 1 Account Type: Checking
2 Account Type: Savings

Part VI ' Metropolitan Commuter Transportation Mobility Tax Worksheet

Starting with 2015 this tax is no longer reported on a Taxpayer Spouse

separate return, but on the IT-201 or IT-203.
1 Complete MCTM Tax Worksheet
LAQUANA E CHAPPELLE 072-72-7356 Page 3
Part VII ' Sales or Use Tax and Voluntary Gifts or Contributions
Sales or Use Tax
1 a If you do not owe any sales or use tax with the return, check this box X
b To calculate tax due on nonbusiness-related items or services costing less than
$1,000 each (excluding shipping and handling) using the sales and use tax chart,
check this box
c If manually calculating the sales or use tax due with the return, check this box and
enter the amount of sales or use tax due on line 4 below
2 If line 1b is checked and you maintained a permanent place of abode in New York
State for sales and use tax purposes for only part of the year, enter the number of
months you maintained a permanent place of abode in New York State
3 Sales tax due based on the sales and use tax chart
4 Sales tax due from ST-140, Individual Purchaser’s Annual Report of Sales & Use Tax
5 Total sales or use tax due (line 2 plus line 3) 0.
Voluntary Gifts or Contributions
Return a Gift to Wildlife Volunteer Firefighting & EMS
Missing/Exploited Children Fund Teen Health Education Fund
Breast Cancer Research Fund Veterans Remembrance Fund
Alzheimer’s Fund Homeless Veterans Fund
Olympic Fund ($2 or $4) Mental Illness Anti-Stigma Fund
Prostate/Testicular Cancer Fund Women’s Cancers Educ Prev Fd
9/11 Memorial Autism Fund
Part VIII ' Additional Information for E-Filed returns
W-2 Verification Indicator given by NYS (See Help).
Tax Shelter Reportable Transaction Attachment Required (Form DTF-686)
Electronic PDF Attachments
PDF’s that you have selected to attach to your state e-file return are listed below.
Description Filename

Part IX - Direct Deposit or Direct Debit Information

Yes No
X Use direct deposit for New York tax refund?
Use electronic funds withdrawal of New York tax payment for the tax return?
Use electronic funds withdrawal of New York tax payment for the amended return? (EF Only)
Bank Information
For direct deposit or electronic funds withdrawal, fill out the information below :
Name of Financial Institution (optional) Banco Popular
Account Type Checking X Savings
Personal or business account Personal X Business
Routing number 026008811
Account number 6806591399
Enter the following information only if you elect direct debit of your state tax payment:
Enter the payment date to withdraw from the account above
State balance-due amount from this return
Electronic funds withdrawal amount due with amended return information:
Enter settlement date to withdraw the tax due amount from the account above
State balance-due amount paid with this amended return
International ACH Transactions
Yes No
X Will the funds for this refund (or payment) go to (or come from) an account outside the U.S.?
Electronic Filing of Estimated Payments
File Form(s) IT-2105 elecronically (Check the boxes below next to the quarters you would like to file)
Payment Payment Date to Date Date Date
Qtr Amount Due Date Withdraw Signed Transmitted Accepted Completed

Bank Information for Estimated Payments

For direct deposit or electronic funds withdrawal, fill out the information below :
Name of Financial Institution (optional)
Account Type Checking Savings
Personal or business account Personal Business
Routing number
Account number
International ACH Transactions for Estimated Payments
Yes No
Will the funds for this refund (or payment) go to (or come from) an account outside the U.S.?
LAQUANA E CHAPPELLE 072-72-7356 Page 4

Part X ' Extension Status

New York State Income Tax Return (IT-201 or IT-203)
Yes No
X Tax return due date extended?
Extended due date
Amount paid with IT-370
New York City Unincorporated Business Tax Return (NYC-202 or NYC-202S)
Yes No
X Has NYC-EXT, "Application for Automatic Extension", been filed for the taxpayer?
Extended due date

X Has NYC-EXT, "Application for Automatic Extension", been filed for the spouse?
Extended due date

Part XI ' Form NYC-1127, Nonresident Employees of the City of New York

Taxpayer Spouse

1 Check the box to indicate the individual(s) who were

employed by the city of New York
2 New York City department or agency where employed
3 Date current employment with the city of New York began
4 If employment ended in 2016, enter final date of
employment

5 For married filing joint taxpayers, file NYC-1127:

Separately, considering only the income/adjustments of the New York City employee
Jointly with spouse, all income/adjustments of both taxpayer and spouse are used to compute
overpayment or balance due

Part XII ' Other Information for Your Tax Return

2-digit special condition code number:

Code A6 Build America Bond Interest ' You (or your spouse if married) included Build
America Bond (BAB) interest in your federal adjusted gross income (AGI)
* Enter total BAB interest included on Form 1040A or Form 1040, line 8a
* Enter BAB interest entered above from NY state or local governments
Code C7 Combat zone ' You (or your spouse if married) qualify for an extension of time to
file and pay your tax due under the combat zone or contingency operation relief
provisions
Code D9 Deceased taxpayer ' If a joint return is being filed, the tax return qualifies for an
automatic 90-day extension to file because either the taxpayer or spouse died within 30
days before the due date of their tax return.
Code K2 Combat zone, killed in action (KIA) ' You are filing a return on behalf of a member of the
armed forces who died while serving in a combat zone
Code M2 Military Spouse Income ' The spouse of a servicemember is exempt from New York state
tax on compensation earned in New York if domiciled in another state (IT-203 filers only)
Code E3 Out of the country ' You (or your spouse if married) qualify for an automatic
two-month extension of time to file your federal return because you are out of the country
Code E4 Nonresident aliens ' You (or your spouse if married) are a federal nonresident alien
Code E5 Extension of time to file beyond six months 'You (or your spouse if married):
- Qualify for an extension of time to file beyond six months because you are outside the
United States and Puerto Rico. Attach a copy of the letter sent to the IRS requesting
additional time to file
- Received a federal extension to qualify for the federal foreign earned income exclusion
and/or the foreign housing exclusion or deduction. Attach a copy of the approved
Form 2350, Application for Extension of Time to File U.S. Income Tax Return
LAQUANA E CHAPPELLE 072-72-7356 Page 5

Part XII ' Other Information for Your Tax Return (continued)

Code 56 Ponzi-type fraudulent investment - You (or your spouse if married) had a Ponzi-type
fraudulent investment reported as a theft loss (itemized deduction) on the federal and
New York tax returns using the federal safe harbor rules
Code P2 Protective Claim - You (or your spouse if married) are claiming a refund on an amended
return (IT-201-X or IT-203-X) based on unresolved issues involving the Tax Department
Code N3 NOL Carryback- You (or your spouse if married) are filing an amended return (IT-201-X
or IT-203-X) due to a net operating loss carryback

If you (or your spouse if married) qualify under a special condition for filing your 2016 tax return
not listed above, enter your 2-digit special condition code number
If applicable, also enter the second 2-digit special condition code number

Third Party Designee:

Yes No
May another person discuss this return with the New York Department of Taxation and Finance?

If Yes, complete the following:

Designee’s name
Designee’s email address
Designee’s phone number
Personal identification number

New York State Underpayment Penalty:

X Allow New York Department of Taxation and Finance to figure the interest and penalty on IT-2105.9
The taxpayer qualified for a 90 day extension of time to pay their first 2016 estimated tax payment

Other Penalties and Interest:

Enter any late filing penalty, late payment penalty, or interest (IT-201 or IT-203)

Long-term Residential Care Deduction (IT-201 and IT-203 Filers):

Yes No
Was the taxpayer a resident in a continuing care retirement community that was issued a
certificate of authority by the New York State Department of Health to operate as a continuing
care retirement community?

Was the spouse a resident in a continuing care retirement community that was issued a
certificate of authority by the New York State Department of Health to operate as a continuing
care retirement community?
Taxpayer Spouse

1 Fees paid during the year that are attributable to the cost of
providing long-term care benefits under a continuing care contract
2 Long-term care insurance deduction age limitation

Part XIII' Amended Return

You are filing a current year New York amended income tax return
Payment made with original return
Refund received from original return

[Link] 02/17/17
 Tax Payments Worksheet 2016
G Keep for your records.

Name Social Security Number

LAQUANA E CHAPPELLE 072-72-7356

Tax Payments for the Current Year

Date Payments

State New York City Yonkers

1 First Payment
2 Second Payment
3 Third Payment
4 Fourth Payment

Additional Payments
5 Payment
Payment
Payment
Payment
Payment

5 a MCTMT Estimates made, from MCTMT Worksheet - Taxpayer 5 a

5 b MCTMT Estimates made, from MCTMT Worksheet - Spouse 5 b
6 Overpayment from previous year applied to current year 6
6 a MCTMT Overpayment from previous year, from MCTMT Wkst - Taxpayer 6 a
6 b MCTMT Overpayment from previous year, from MCTMT Wkst - Spouse 6 b
7 Amount paid with current year extension 7

8 Total tax payments 8

New York State Income Tax Withheld for the Current Year

9 State withholding on Forms W-2 9 416.

10 State withholding on Forms W-2G 10
11 State withholding on Forms 1099-R 11
12 a State withholding on Forms 1099-MISC 12 a
12 b State withholding on Forms 1099-G 12 b
12 c State withholding on Forms 1099-K 12 c
13 Other state tax withholding 13

14 Total state income tax withheld 14 416.

City Income Tax Withheld for the Current Year

15 Total City of New York withholding 15 300.

16 Total Yonkers withholding 16
17 Section 1127 withholding 17

Section 414(h) and 125 Withholding

18 Public employee 414(h) retirement contributions - subject to New York Tax 18

19 Public employee 414(h) retirement contributions - not subject to New York
Tax 19
20 Total City of New York withholding (IRC 125) - subject to New York Tax 20
21 Total City of New York withholding (IRC 125) - not subject to New York Tax 21

22 Date return will be filed and balance paid 22

[Link] 10/18/16
 New York State School District/County 2016
Selection Worksheet
G Keep for your records

Name as Shown on Return Social Security No.

LAQUANA E CHAPPELLE 072-72-7356

Listed below are the counties in New York state. The school districts associated with each county are
available by clicking on the field next to your county of [Link] should select the appropriate
school district. Based on the school district selected, the program will automatically select the matching
school district code.

New York Counties

Albany Niagara
Allegany Oneida
Broome Onondaga
Cattaraugus Ontario
Cayuga Orange
Chautauqua Orleans
Chemung Oswego
Chenango Otsego
Clinton Putnam
Columbia Rensselaer
Cortland Rockland
Delaware St. Lawrence
Dutchess Saratoga
Erie Schenectady
Essex Schoharie
Franklin Schuyler
Fulton Seneca
Genesee Steuben
Greene Suffolk
Hamilton Sullivan
Herkimer Tioga
Jefferson Tompkins
Lewis Ulster
Livingston Warren
Madison Washington
Monroe Wayne
Montgomery Westchester
Nassau Wyoming
New York City Brooklyn Yates

[Link] 04/30/15
 New York State 2016
Wages/Self-Employment Income Allocation
G Keep for your records

Name as Shown on Return Social Security No.

Part I ' New York Wage Allocation

Taxpayer

Allocate by Allocate by New York

Formula Percent Wages

SCO FAMILY OF SERVICES 8,526.

UNITED STATES POSTAL SERVICE EAG AN ACCOUNTING SERVICE CENTER 3,228.

Spouse

Allocate by Allocate by New York

Formula Percent Wages

See Tax Help for details.

Part II ' State Self-Employment Income Allocation

Taxpayer

Type State Allocation State Self-

of Code Percent Employment
Business Income

Spouse

Type State Allocation State Self-

of Code Percent Employment
Business Income

See Tax Help for details.

[Link] 04/30/15
 New York City/Yonkers 2016
Wages/Self-Employment Income Allocation
G Keep for your records

Name as Shown on Return Social Security No.

Part I ' City Wage Allocation

Taxpayer

City Alloc. % City Wages

Code Method

NYC SCO FAMILY OF SERVICES 8,526.

NYC UNITED STATES POSTAL SERVICE EAG AN ACCOUNTING SERVICE CENTER 3,228.

Spouse

City Alloc. % City Wages

Code Method

See Tax Help for details.

Part II ' City Self-Employment Income Allocation

Taxpayer

Type City Alloc. % City Self-

Code Method Employment
Income

Spouse

Type City Alloc. % City Self-

Code Method Employment
Income

See Tax Help for details.

 Form IT-201-D College Tuition Itemized Deduction Worksheet 2016
Line 15 G Keep for your records

Name as Shown on Return Social Security No.

1 Amount from Form IT-272, line 3 1

If your filing status is:
? 1 or 3 and the amount on Form IT-201, line 33 is $100,000 or less; or
? 4 and the amount on Form IT-201, line 33 is $150,000 or less; or
? 2 or 5 and the amount on Form IT-201, line 33 is $200,000 or less
skip lines 2 through 4 and enter the amount from line 1 on line 5. All others
continue with line 2.

2 Amount, if any, from your itemized deduction schedule,

line 14 2
(If the amount on line 2 is 0 skip lines 3 and 4
below and see the instructions to compute the amount
to enter on line 5.)
3 Amount from your itemized deduction schedule, line 12 3
4 Divide line 2 by line 3 and round to the fourth decimal place 4
5 Multiply line 1 by the amount on line 4. This is your college tuition
itemized deduction 5

[Link] 04/30/15
 College Tuition Qualified Expenses 2016
Optimization Worksheet
G Keep for your records

Name as Shown on Return Social Security No.

LAQUANA E CHAPPELLE 072-72-7356

Part I ' Complete columns A through G below for each eligible student for whom you paid qualified college
tuition expenses.
A Do not list the same student more than once
A List the EIN and name of the college that was last attended
A Tuition payments for enrollment or attendance in a course of study leading to the granting of a post
baccalaureate or other graduate degree do not qualify for the college tuition credit

A C D F G
Student’s name Student EIN of college Under- Qualified college
B Type E graduate tuition expenses
Student’s SSN College name expense? paid in 2016

Yes
No
Yes
No
Yes
No

2 Total tuition (sum of column G) 2

3 Total tuition eligible for the College Tuition Credit or Itemized Deduction 3

Part II ' Optimization of College Tuition Credit vs College Tuition Itemized Deduction (IT-201 Filers Only)

Taxpayers who file IT-201, Resident Income Tax Return and itemize deductions can use college
tuition expenses as an itemized deduction or used to calculate a tax credit.

1 Check this box to launch the optimizer now. This will automatically determine whether the
deduction or the credit generates the lowest tax

Caution: A. If you make any changes to this return after launching the automatic optimization above,
you MUST optimize again by rechecking the box on Line 1 above.
B. If you check the Optimizer box on Line 1 above, wait until the calculations are done before
you continue. Refer to the calculation indicator at the bottom right. It will indicate refund or
tax due when calculations are done.
2 Automatic - Check to use the Deduction or Credit choices calculated in column (b) below X
OR
3 Manual - Check to use the Deduction or Credit choices you entered in column (a) below

(a) (b)
Manual: Automatic:
Choose Credit or Program Choice
Deduction

Check the box to use your qualified college tuition expenses to

calculate a credit X
Check the box to use your qualified college tuition expenses as an
itemized deduction

Part III ' Net Refund/Balance Due

Refund 3070
Balance Due
 Tax Computation Worksheet 2016
G Keep for your records

Name as Shown on Return Social Security No.

LAQUANA E CHAPPELLE 072-72-7356

Married filing jointly and qualifying widow(er) Worksheets 1 through 4

- If your New York adjusted gross income is more than $106,950, but not more than $2,140,900, and
taxable income is $160,500 or less, then you must compute your tax using worksheet 1

Tax Computation Worksheet 1

1 Enter your New York adjusted gross income from Form IT-201, line 33 or
Form IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 6.45% (.0645). If line 1 is $156,950 or more, enter line 3
amount on line 9 below, skip lines 4 through 8 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 Enter the excess of line 1 over $106,950 6
7 Divide line 6 by $50,000 and round to the fourth decimal place 7
8 Multiply line 5 by line 7 8
9 Add lines 4 and 8. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 9

- If your New York adjusted gross income is more than $160,500, but not more than $2,140,900 and your
taxable income is more than $160,500 but not more than $321,050, compute your tax using worksheet 2

Tax Computation Worksheet 2

1 Enter your New York adjusted gross income from Form IT-201, line 33 or
Form IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 6.65% (.0665). If line 1 is $210,500 or more, enter line 3
amount on line 11 below, skip lines 4 through 10 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 Enter $677 on line 6 6
7 Subtract line 6 from line 5 7
8 Enter the excess of line 1 over $160,500 8
9 Divide line 8 by $50,000 and round to the fourth decimal place 9
10 Multiply line 7 by line 9 10
11 Add lines 4, 6 and 10. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 11

- If your New York adjusted gross income is more than $321,050, but not more than $2,140,900 and your
taxable income is more than $321,050, compute your tax using worksheet 3 on page 2.
LAQUANA E CHAPPELLE 072-72-7356 Page 2

Tax Computation Worksheet 3

1 Enter your New York adjusted gross income from Form IT-201, line 33 or Form
IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 6.85% (.0685). If line 1 is $371,050 or more, enter line 3
amount on line 11 below, skip lines 4 through 10 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 Enter $998 on line 6 6
7 Subtract line 6 from line 5 7
8 Enter the excess of line 1 over $321,050 8
9 Divide line 8 by $50,000 and round to the fourth decimal place 9
10 Multiply line 7 by line 9 10
11 Add lines 4, 6 and 10. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 11

- If your New York adjusted gross income is more than $2,140,900, compute tax using worksheet 4 below.

Tax Computation Worksheet 4

1 Enter your New York adjusted gross income from Form IT-201, line 33 or Form
IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 8.82% (.0882). If line 1 is $2,190,900 or more, enter line 3
amount on line 11 below, skip lines 4 through 10 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 If line 2 is $160,500 or less, enter $677 on line 6. If line 2 is more than
$160,500 but not more than $321,050, enter $998 on line 6. If line 2 is more
than $321,050, enter $1,640 on line 6 6
7 Subtract line 6 from line 5 7
8 Enter the excess of line 1 over $2,140,900 8
9 Divide line 8 by $50,000 and round to the fourth decimal place 9
10 Multiply line 7 by line 9 10
11 Add lines 4, 6 and 10. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 11

Single and married filing separately Worksheets 5 through 7

- If your New York adjusted gross income is more than $106,950, but not more than $1,070,350, and
taxable income is $214,000 or less, then you must compute your tax using worksheet 5 on page 3.
LAQUANA E CHAPPELLE 072-72-7356 Page 3

Tax Computation Worksheet 5

1 Enter your New York adjusted gross income from Form IT-201, line 33 or Form
IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 6.65% (.0665). If line 1 is $156,950 or more, enter line 3
amount on line 9 below, skip lines 4 through 8 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 Enter the excess of line 1 over $106,950 6
7 Divide line 6 by $50,000 and round to the fourth decimal place 7
8 Multiply line 5 by line 7 8
9 Add lines 4 and 8. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 9

- If your New York adjusted gross income is more than $214,000, but not more than $1,070,350, and
taxable income is more than $214,000, then you must compute your tax using worksheet 6 below.

Tax Computation Worksheet 6

1 Enter your New York adjusted gross income from Form IT-201, line 33 or
Form IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 6.85% (.0685). If line 1 is $264,000 or more, enter line 3
amount on line 11 below, skip lines 4 through 10 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 Enter $497 on line 6 6
7 Subtract line 6 from line 5 7
8 Enter the excess of line 1 over $214,000 8
9 Divide line 8 by $50,000 and round to the fourth decimal place 9
10 Multiply line 7 by line 9 10
11 Add lines 4, 6 and 10. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 11

- If your New York adjusted gross income is more than $1,070,350, compute your tax using worksheet 7
on page 4.
LAQUANA E CHAPPELLE 072-72-7356 Page 4

Tax Computation Worksheet 7

1 Enter your New York adjusted gross income from Form IT-201, line 33 or Form
IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 8.82% (.0882). If line 1 is $1,120,350 or more, enter line 3
amount on line 11 below, skip lines 4 through 10 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 If line 2 is $214,000 or less, enter $497 on line 6. If line 2 is more than
$214,000, enter $925 on line 6 6
7 Subtract line 6 from line 5 7
8 Enter the excess of line 1 over $1,070,350 8
9 Divide line 8 by $50,000 and round to the fourth decimal place 9
10 Multiply line 7 by line 9 10
11 Add lines 4, 6 and 10. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 11

Head of household Worksheets 8 through 10

- If your New York adjusted gross income is more than $106,950, but not more than $1,605,650, and
taxable income is $267,500 or less, then you must compute your tax using worksheet 8 below.

Tax Computation Worksheet 8

1 Enter your New York adjusted gross income from Form IT-201, line 33 or Form
IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 6.65% (.0665). If line 1 is $156,950 or more, enter line 3
amount on line 9 below, skip lines 4 through 8 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 Enter the excess of line 1 over $106,950 6
7 Divide line 6 by $50,000 and round to the fourth decimal place 7
8 Multiply line 5 by line 7 8
9 Add lines 4 and 8. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 9

- If your New York adjusted gross income is more than $267,500, but not more than $1,605,650, and
taxable income is more than $267,500, then you must compute your tax using worksheet 9 on page 5.
LAQUANA E CHAPPELLE 072-72-7356 Page 5

Tax Computation Worksheet 9

1 Enter your New York adjusted gross income from Form IT-201, line 33 or
Form IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 6.85% (.0685). If line 1 is $317,500 or more, enter line 3
amount on line 11 below, skip lines 4 through 10 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 Enter $720 on line 6 6
7 Subtract line 6 from line 5 7
8 Enter the excess of line 1 over $267,500 8
9 Divide line 8 by $50,000 and round to the fourth decimal place 9
10 Multiply line 7 by line 9 10
11 Add lines 4, 6 and 10. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 11

- If your New York adjusted gross income is more than $1,605,650, compute your tax using worksheet 10
below.

Tax Computation Worksheet 10

1 Enter your New York adjusted gross income from Form IT-201, line 33 or Form
IT-203, line 32 1
2 Enter your taxable income from Form IT-201, line 38 or Form IT-203, line 37 2
3 Multiply line 2 by 8.82% (.0882). If line 1 is $1,655,650 or more, enter line 3
amount on line 11 below, skip lines 4 through 10 3
4 Enter your New York State tax on the line 2 amount from the New York State
tax rate schedule 4
5 Subtract line 4 from line 3 5
6 If line 2 is $267,500 or less, enter $720 on line 6. If line 2 is more than
$267,500, enter $1255 on line 6 6
7 Subtract line 6 from line 5 7
8 Enter the excess of line 1 over $1,605,650 8
9 Divide line 8 by $50,000 and round to the fourth decimal place 9
10 Multiply line 7 by line 9 10
11 Add lines 4, 6 and 10. Enter here and Form IT-201, line 39 or Form IT-203,
line 38 11

[Link] 10/07/16
 Tax Summary 2016
G Keep for your records

Name(s)
LAQUANA E CHAPPELLE

Federal Adjusted Gross Income 11,754.

New York Additions
New York Subtractions
New York Adjusted Gross Income 11,754.
Itemized or Standard Deduction 11,150.
Dependent Exemptions 2,000.
New York Taxable Income
Tax 0.
New York State Credits 90.
Other New York State Taxes
Total New York State Taxes
New York City Taxes
MCTMT
Yonkers City Taxes
Sales or Use Tax 0.
Voluntary Gifts/Contributions
Total New York State, New York City and Yonkers
Taxes, Use Tax and Voluntary Gifts/Contributions
Total Payments and Credits 3,070.
Penalty Amount
Refund 3,070.
Amount Owed
LAQUANA E CHAPPELLE 072-72-7356 1

Smart Worksheets from your 2016 New York Tax Return

SMART WORKSHEET FOR: IT-215: Claim for Earned Income Credit

Form IT-215, New York City Earned Income Credit Smart Worksheet

1 Amount of federal EIC claimed (from Form IT-215, line 10) 4,710.
2 New York City EIC rate 5% (.05) 0.05
3 Allowable New York City EIC (multiply line 1 by line 2) 236.
? If your New York City filing status Married filing separate return, also
complete line 4.
? Part-year New York city residents must also complete lines 5 through 9
below.
? All others enter the line 3 amount on Form IT-215, line 27; also on
Form IT-201, line 70
4 If your New York City filing status is Married filing separate return, the NYC EIC
credit on line 3 can be divided between spouses in any manner you wish. Enter
on line 4 the amount of credit you are claiming and and enter your federal
adjusted gross income below
? Federal adjusted gross income (from federal Form 1040EZ, line 4, Form
1040A, line 22, or Form 1040, line 38) 4a
New York City part-year resident earned income credit
5 New York City earned income credit (from line 3 or line 4 above)
6 Enter the amount from Form IT-360.1, line 20, Column B
7 Enter the amount from Form IT-360.1, line 20, Column A
8 Divide line 6 by line 7 (round the result to four decimals; cannot exceed 1.000)
9 New York City part-year EIC (multiply line 5 by line 8). Enter this amount on
Form IT-215, line 27; also enter on Form IT-201, line 70 or on Form IT-203-ATT,
line 11